qualcomm philippines project analysis

Qualcomm Wireless ReachPhilippines PartnershipImproving Health Record Systems in Rural Health Units

Initial Project Analysis

Submitted To

Qualcomm Wireless ReachLinda Lee, Government Affairs

United States Agency for International DevelopmentMs. Maria Paz De Sagun, Agreement Officer’s Technical Representative

USAID HealthGov ProjectHarry Roovers, Chief of Party

Submitted ByRTI InternationalP.O. Box 12194Research Triangle Park, NC 27709-2194Telephone: 919-541-6000

RTI Technical Point of ContactGordon M. CressmanCenter for Information, Communication, and TechnologyTelephone: +1 919 541-6363Fax: +1 919 541-6621E-mail: [email protected]

11 June 2009 DRAFT

Initial Project Analysis and Preliminary Work Plan - DRAFT 11 June 2009

Qualcomm Philippines Wireless Reach Partnership Page ii

Contents

1 Introduction and Background............................................................................................. 12 Problem Statement............................................................................................................ 63 Problem Analysis..............................................................................................................144 Project Objectives ............................................................................................................235 Proposed Solution ............................................................................................................266 Relationships with other Systems.....................................................................................327 Proposed Partners and their Roles...................................................................................378 Engaging Other Stakeholders...........................................................................................489 Project Resources ............................................................................................................5410 Sustaining the Solution.....................................................................................................5411 Scaling Up the Solution ....................................................................................................5712 Management and Staffing ................................................................................................5813 Monitoring and Evaluation ................................................................................................64


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Acronyms and Abbreviations

2.5G.................... Second and a half generation wireless communications technology3G....................... Third generation wireless communications technologyAIDS ................... Acquired Immune Deficiency SyndromeAMPATH............. Academic Model for the Prevention and Treatment of HIV/AIDSAMRS ................. AMPATH Medical Record SystemAOTR.................. Agreement Officers Technical RepresentativeAPAMI ................ Asia Pacific Association for Medical InformaticsART .................... Antiretroviral TherapyARV .................... AntiretroviralBART .................. Baobab HIV Treatment SystemBHS .................... Barangay Health StationBIHC................... Bureau of International Health CooperationCB....................... Community BasedCBMS ................. Community Based Monitoring SystemCDC.................... United States Centers for Disease ControlCEDPA ............... Centre for Development and Population ActivitiesCHITS................. Community Health Information Tracking SystemCHD.................... Center for Health DevelopmentCHO.................... City Health OfficerCHU.................... City Health UnitCICT ................... Commission on Information and Communications TechnologyCIDRZ................. Center for Infectious Disease Research in ZambiaCOP.................... Chief of PartyCSR.................... Corporate Social ResponsibilityDDB .................... Dangerous Drugs BoardDILG ................... Department of Interior and Local GovernmentDOH.................... Department of HealthEMR.................... Electronic Medical RecordsF1 ....................... FOURmula ONE for HealthFHSIS ................. Field Health Service Information SystemFP....................... Family PlanningGDA.................... Global Development AllianceGPPHI ................ Global Partnership for Public Health InformaticsGPS.................... Global Positioning SystemHealthGov........... USAID Strengthening Local Governance for Health ProjectHMIS................... Health Management Information SystemHMN ................... Health Metrics NetworkHOMIS................ Hospital Operations and Management Information SystemHSRA.................. Health Sector Reform AgendaICD ..................... International Classification of DiseasesICHSP................. Integrated Community Health Services ProjectICT...................... Information and Communication TechnologyIDTOMIS............. Integrated Drug Test Operation and Management Information SystemILHZ.................... Inter-Local Health ZoneIMIA .................... International Medical Informatics AssociationIMS ..................... Information Management SystemsIR........................ Intermediate Result


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LCE..................... Local Chief ExecutiveLCP..................... League of Cities of the PhilippinesLGC .................... Local Government CodeLGU .................... Local Government UnitLMP .................... League of Municipalities of the PhilippinesLPP..................... League of Provinces of the PhilippinesM&E.................... Monitoring and EvaluationMCH ................... Maternal and Child HealthMDG ................... Millennium Development GoalMHO ................... Municipal Health OfficerNAPC.................. National Anti-Poverty CommissionNCDPC............... National Center for Disease Prevention and ControlNEC.................... National Epidemiology CenterNEDSS ............... National Electronic Disease Surveillance SystemNEISS................. National Electronic Injury Surveillance SystemNHAGIS.............. National Health Atlas Geographic Information SystemNNC.................... National Nutrition CouncilNSCB.................. Philippine National Statistical Coordination BoardNSO.................... National Statistical OfficeNThC .................. National Telehealth CenterOIDCI.................. Orient Integrated Development Consultants, Inc.OP ...................... Operational PlanOpenMRS ........... Open Medical Record SystemOSHCA............... Open Source Health Care AlliancePEPFAR ............. President’s Emergency Plan for AIDS ReliefPHIP ................... Province-wide Investment Plan for HealthPMIS................... Philippine Medical Informatics SocietyPHO.................... Provincial Health OfficePHIC ................... Philippine Health Insurance Corporation (See PhilHealth)PHSID................. Public Health Surveillance and Informatics DivisionPITAHC............... Philippine Institute of Traditional & Alternative Health CarePhilHealth ........... Philippine Health Insurance Corporation (See PHIC)PHIN ................... Philippine Health Information NetworkPNAC.................. Philippine National AIDSPOPCOM............ Population CommissionRESU.................. Regional Epidemiology Surveillance UnitRHU.................... Rural Health UnitRHUMIS.............. Rural Health Unit Management Information SystemPMAC ................. Prevention and management of abortion complicationsPNGOC............... Philippines NGO Council on Population, Health and WelfareRTI...................... RTI InternationalSO ...................... Strategic ObjectiveSOAg .................. Strategic Objective AgreementSTI ...................... Sexually Transmitted Infections (STI)TA....................... Technical AssistanceTAHC.................. Traditional Alternative Health CareTAP..................... Technical Assistance ProviderTB....................... TuberculosisTBD .................... To Be Determined


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TWG ................... Technical Working GroupUAB .................... University of Alabama at BirminghamUMTS ................. Universal Mobile Telecommunications SystemUP....................... University of the PhilippinesUSAID................. United States Agency for International DevelopmentTSU .................... Tarlac State UniversityVAWC................. Violence against women and childrenWCDMA.............. Wideband Code Division Multiple AccessWHO................... World Health OrganizationZEPRS................ Zambian Electronic Perinatal System

Project Analysis and Preliminary Work Plan 8 May 2009 DRAFT

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Qualcomm Wireless ReachPhilippines PartnershipImproving Health Record Systems in Rural Health Units

1 Introduction and Background

This document builds on a grant awarded by the Qualcomm Wireless Reach Initiative (WirelessReach) to RTI International (RTI) in conjunction with RTI implementation of the United StatesAgency for International Development (USAID) HealthGov project. This Wireless Reach projectwill support USAID HealthGov project results by pilot testing a system to improve health recordsystems in rural health units (RHU). This system will be designed to improve access to accurateand comprehensive patient information for clinicians, reduce the amount of time required formonthly reporting from RHUs to the Field Health Service Information System (FHSIS), andimprove the timeliness and quality of data reporting to the FHSIS. The system will useQualcomm 3G wireless technology to transmit public health status and services data from eachRural Health Unit (RHU) to the appropriate provincial health office over an existing mobilephone network.

Using Wireless Reach grant funding, RTI technical experts will help a local technical assistanceprovider, Tarlac State University (TSU), to adapt existing free and open source software to meetthe routine patient record-keeping needs of RHUs in the Philippines and to use Qualcomm 3Gwireless technology to transmit data over the Smart Communications mobile phone network tomeet the routine data reporting requirements of the FHSIS. This approximately one-year pilotproject will test this system in a limited number of targeted RHUs and Local Government Units(LGUs)1 in Tarlac Province. This will be done in partnership with the USAID HealthGov project,the Tarlac Provincial Health Office (PHO), the Philippine Department of Health (DOH), TSU,Smart Communications, and other health information system stakeholders in the Philippines.

The objective of this project is to produce a system that has the official support of the DOH, canbe scaled up to additional RHUs in each LGU based on local demand and support, and can besustained and continually enhanced using local capacity. Our hope is that close collaborationwith clinicians2, the DOH, and other national health information and health informaticsstakeholders, careful selection of appropriate technology, beneficial private sector partnerships,and a design that can be replicated, scaled, and sustained by LGUs will make this systemattractive to other provinces. Once the approximately one-year pilot project has beencompleted, project partners will determine the next steps regarding further enhancement anddeployment of the system.

The remainder of this section describes how this project supports USAID HealthGov objectives.It also provides background on how the problem was identified, how the solution wasconceptualized, why and how RTI obtained funding support from the Qualcomm WirelessReach Initiative to supplement HealthGov resources. Finally, this section describes what RTIhas done to date to engage stakeholders and build momentum for a Wireless Reach Philippines

1Municipalities and cities

2Physicians, nurses, midwives, and other healthcare workers providing care to patients



Partnership to support this activity, and the importance of getting our project team on the groundto continue the work of engaging partners, further defining partner roles and commitments, andgathering the information needed to complete a detailed work plan for the pilot project.

The following sections of this document provide more detailed information about the QualcommWireless Reach Philippines Partnership project. Sections 2 through 5 provide a more detailedanalysis of the problem to be addressed, specific objectives, and the solution being proposed.Section 6 describes other related health information system components in the Philippines andhow they relate to the proposed system. Section 7 describes proposed partners and theirproposed roles. Section 8 describes other stakeholders and how they will be engaged. Section9 explains the resource limitations of the activity. Section 10 describes challenges to sustainingthe system and how they will be addressed. Section 11 describes how, contingent on the resultsof the pilot, the system can be scaled up to all RHUs in Tarlac Province, and to other provinces.Section 12 explains how we propose to organized and managed the activity, and introducesmembers of the project implementation team. Finally, Section 13 explains how this activity willbe monitoring and evaluated, and provides an illustrative results framework with indicators andmilestones.

1.1 USAID HealthGov Project Objectives

The Strengthening Local Governance for Health (HealthGov) Project is USAID’s flagship projectdesigned to strengthen local government units’ (LGU) commitment to and support for publichealth services and their capacity to plan, provide, manage, and finance quality health services,particularly family planning (FP), maternal and child health (MCH), tuberculosis (TB), andHIV/AIDS services, in a manner that can be sustained. The project puts premium on gettinglocal leaders to invest in health. It focuses on empowering LGU staff and developing theircapacity to meet the organizational, financial, and systems development challenges to addressemerging health needs. The HealthGov Project is implemented by RTI International, inpartnership with JHPIEGO, the Centre for Development and Population Activities (CEDPA), thePhilippines NGO Council on Population, Health and Welfare (PNGOC), and Orient IntegratedDevelopment Consultants, Inc. (OIDCI).

Focusing on sustainable solutions, HealthGov will develop LGU capacity for continuousparticipatory problem solving to improve health systems, build LGU support for investing inhealth, and strengthen the participation and advocacy skills of civil society. To accelerate theseefforts, HealthGov will develop a network of technical assistance providers or TAPs (e.g.,universities, NGOs, consultants, government agencies) that LGUs may engage to provide themwith customized training and technical assistance (TA) services to solve key problems. Inaddition to improved health outcomes, sustainable “success” as a result of HealthGovassistance will be achieved when an LGU can properly identify its health sector problems andpractical solutions in a participatory manner, and has access to sufficient resources (financialand technical, internal and external) to solve these problems.

HealthGov will help broker and develop long-term sustainable relationships between thefollowing:

(1) LGUs and local technical assistance provider organizations to help enhance LGU skillsand knowledge, and



(2) LGUs and their constituents to improve the quality and accessibility of health services.

HealthGov is focusing on four key activity areas that correspond to the results framework ofUSAID’s SO3, which is as follows:

USAID SO3: Improved Family Health Sustainably Achieved.

The first of these four activity areas corresponds to Intermediate Result 1.1 of the HealthGovproject results framework, Strengthening LGU Management Systems, which is explained in thefollowing section.

1.2 HealthGov IR 1.1: Strengthening LGU Management Systems

HealthGov activities targeted at achieving this intermediate result are designed to help LGUs todo the following:

(1) effectively integrate health planning and budgeting functions into the overall governmentsystem;

(2) improve management systems including inter-local health zone (ILHZ) management,planning and budgeting, financial management, drug/commodity logistics andprocurement, and the use of self-assessment techniques and health managementinformation systems (HMIS) to diagnose priority problems; and

(3) institutionalize multi-stakeholder coordination mechanisms at the provincial level forparticipatory planning, leveraging resources, and sharing best practices.

Developing technical assistance providers (TAPs) and public-private partnerships that helpLGUs improve their health management information systems is therefore central to achievingHealthGov IR 1.1. The core of the national health management information system in thePhilippines is the FHSIS.

1.3 HealthGov Monitoring and Evaluation

The USAID HealthGov project Monitoring and Evaluation (M&E) plan includes performanceindicators designed to measure progress towards achieving project objectives. Indicatorsdesigned to measure progress towards achieving Intermediate Result 1.1 and are as follows:

1.1B # of LGUs with improved health information systema. # of provinces with at least 75% of component LGUs that submitted the last

FHSIS quarterly report of the current year on timeb. # of provinces with an average delay of less than 2 weeks in the submission of

the last FHSIS quarterly reports of the current year by component LGUsc. # of component LGUs that submitted the last FHSIS quarterly report of the

current year on time to the PHOd. # of LGUs that have ever conducted CBMS or CB Health and Living Standard

Information Survey as of the current year

Three of the four project performance indicators in this category are designed to measureimprovements in the timeliness of FHSIS reporting by LGUs.



In addition to HealthGov project performance indicators, the HealthGov project is responsible forcollecting data for a large number of USAID Operational Plan (OP) indicators designed tomeasure progress towards results across USAID programs. Many of these indicators dependdirectly or indirectly on FHSIS reports to provide the necessary indicator data. This isparticularly true in the major areas of maternal and child health, and family planning andreproductive health.

USAID established a Strategic Objective Agreement (SOAg) M&E Technical Working Group(TWG) composed of the M&E specialists and other concerned project staff of the differentUSAID Cooperating Agencies (HPDP, HealthGov, TB LINC, SHIELD-ARMM, PRISM, A2Z, andHealthPro) to develop and coordinate detailed plans for collecting, analyzing, and reportingindividual project performance and USAID OP indicators. TWG members recognize that theFHSIS is a critical source of data for many project performance and OP indicators. Over theperiod of a year, TWG members repeatedly expressed concerns in TWG meetings about thequality of FHSIS data. As noted in previous sections, improving the health managementinformation system is part of the HealthGov project results framework.

1.4 Examining FHSIS Data Quality Problems in Tarlac Province

In March 2008 the HealthGov team3 examined FHSIS data flow and quality issues with theProvincial Health Office (PHO) and the data management unit of the DOH Center for HealthDevelopment (CHD) representative office in Tarlac Province. PHO staff members explained theflow of data from Rural Health Units (RHUs) to the FHSIS, and demonstrated how and whyFHSIS data quality problems originate in Rural Health Units (RHUs.) They also describedproblems in getting RHUs to submit FHSIS reports on time. They attributed both problems to thetime and effort that it takes for RHU personnel to complete routine FHSIS reports from theirexisting manual patient records systems.

The HealthGov team then met with the Provincial Health Officer to discuss previous and existingefforts to improve the health information system and discuss the feasibility of an electronicmedical record system for RHUs. Finally, the Health team visited Tarlac State University (TSU)to determine whether TSU might become an effective local technical assistance provider tosupport the introduction of electronic records into RHUs.

1.5 Conceptualizing a Solution

RTI developed a draft concept paper and budget based on RTI experience with similar projectsin other countries, our findings in Tarlac, and our subsequent research. The proposed solutionfocused on introducing an electronic medical record system in RHUs that could be used tosubmit routine FHSIS data reports electronically to the PHO. RTI proposed to adapt ZEPRS, aproven free and open source electronic patient record system that RTI helped to develop inZambia, to the standards of care in the Philippines. Members of the HealthGov team reviewedthe concept paper and provided some input based on HealthGov activities in Tarlac. Afterconsulting with the HealthGov team, RTI decided to apply to the Qualcomm Wireless ReachInitiative for core grant funding to support this activity.

3Conrad Castillo (HealthGov Provincial Coordinator), Honorio Alumno (HealthGov Management

Information System Advisor), and Gordon Cressman (Senior Management Information System Advisor)



1.6 Engaging the Qualcomm Wireless Reach Initiative for Support

Qualcomm Incorporated (Qualcomm) is a U.S.-based wireless telecommunications researchand development company4. Qualcomm designs, manufactures and markets digital wirelesstelecommunications products and services. Qualcomm believes access to advanced wirelessvoice and data services improves people’s lives. The Wireless Reach initiative supportsprograms and solutions that bring the benefits of connectivity to developing communitiesglobally. By working with partners, Wireless Reach projects create new ways for people tocommunicate, learn, access healthcare and reach global markets.

RTI worked with Wireless Reach to provide advanced 3G wireless Internet access to schoolsunder the Alianzas Guatemala program. The Alianzas Guatemala program5, managed by RTI, isarguably one of the most successful USAID Global Development Alliances (GDAs). RTI is alsoimplementing the Wireless Reach Kenya Partnership project6. This project uses free and opensource software developed by RTI to improve the management of ARV pharmaceutical suppliesand ART patient records in health centers in Nairobi. The project is using Qualcomm 3G7

wireless broadband technology over project partner Telkom Kenya’s mobile phone network toenable health centers to submit routine reports and requests for re-supply electronically to thecentral supply warehouse.

Qualcomm normally provides one year of grant funding to each Wireless Reach project.Qualcomm may provide one or two additional years of grant funding, depending on projectprogress and available Wireless Reach funds. Qualcomm often engages other partners,including USAID, during the initial project year to lay a firm foundation for subsequent scale-upand long-term sustainability of the intervention. On 15 December 2008 Qualcomm notified RTIthat they intended to award grant funding to RTI for implementing the Qualcomm WirelessReach Philippines Partnership pilot project. RTI and Qualcomm finalized this grant agreementApril 1, 2009.

1.7 Forming the Wireless Reach Philippines Partnership

Since being notified by Qualcomm in December 2009 that a grant would be awarded, RTI hasworked with the USAID HealthGov team and the Tarlac PHO to establish contacts with TSU,Smart Communications, and the DOH to discuss this activity and begin the work of building aWireless Reach Philippines Partnership. The purpose of this public-private partnership is tosupport this activity through the approximately twelve-month pilot project and, contingent on thesuccess of the pilot, over time to extend the benefits of this system to all RHUs in TarlacProvince. Eventually we hope this system will be adopted by other provinces throughout thecountry. RTI has also continued to gather and analyze information about other healthinformation system efforts in the Philippines and to broaden our contacts with otherstakeholders in this sector. For example, we have shared information and engaged indiscussions with the Medical Informatics Unit of the National Telehealth Center (NThC), Collegeof Medicine, of the University of the Philippines. This is to ensure that this activity in Tarlac

4See www.qualcomm.com for more information.

5See www.alianzasguatemala.org for more information.

6See www.rtidemo.org/front/node/170 for more information.

7Third generation (3G) mobile phone networks enable cellular network operators to offer a wide range of

advanced services including broadband wireless Internet connectivity.



builds on and complements other information system efforts, results in a system that can besustained by LGUs, and has the support of the DOH.

RTI has deployed its project team on the ground to continue the work of building thepartnership, and to gather the information needed to develop a detailed work plan. We hope thatthis document answers many questions concerning the feasibility of the proposed activity, how itrelates to other health information system efforts in the Philippines, and how it will be integratedwith USAID HealthGov technical assistance efforts in Tarlac Province.

2 Problem Statement

The FHSIS is the major source of data for health sector policy analysis and planning at all levelsof the public health system in the Philippines. The system provides information on public healthprograms including the following:

Maternal and Child Health Nutrition Family Planning Expanded Program on Immunization Dental Health Communicable Disease Prevention and Control (TB, Malaria, Schistosomiasis, Leprosy) Environmental Health Vital Statistics (Natality, Mortality, Population) Notifiable Disease Reporting

Exhibit 1 is a diagram showing the relationship between patient-level data, aggregated datareporting for vertical programs, and aggregated data for FHSIS reporting.

The FHSIS was conceptualized in 1987 to streamline a previous reporting system that nursesand midwives complained was overly burdensome and required time that otherwise was neededfor patient care. The FHSIS was implemented nationwide in 1989. In 1991, barely a year afterthe national implementation of the FHSIS, the Local Government Code (LGC) transferredmanagement and provision of health services to LGUs. In 1998 the Health Sector ReformAgenda (HSRA), carried out by the DOH, implemented the transfer of responsibilities for publichealth service delivery to LGUs.

Since 1991 the FHSIS has undergone several major revisions to adapt to changes broughtabout by the LGC and HSRA. In 2007 the FHSIS team, including regional coordinators, initiateda program to further strengthen the FHSIS. This effort included creating an indicator datadictionary, revising FHSIS recording and reporting forms, and drafting new FHSIS implementingguidelines. Efforts also included examining information needs, data transmission andprocessing, routine data collection, non-routine data collection, and use of information fordecision making. A new version of the FHSIS software (FHSIS 2008) has been developed toincorporate changes. This version is now being rolled out to regions and provinces. Keyremaining problems noted by the FHSIS team include delayed submission of reports, poor



quality data, and limited utilization by decision makers at various levels of the health caresystem.8

A study of Philippine public healthinformation systems in 19959 found thatmanual production of required reportsconsumed 40% of the time of field healthpersonnel and resulted in duplicated effortand significant delays in processing. In 2005a study by Tolentino et al10 in busy publichealth centers concluded that manual entryof patient information into multiple and oftenoverlapping vertical program registers,laborious manual reporting procedures, andlack of feedback to clinicians, combined tonegatively affect data quality and thetimeliness of reporting.

In July 2007 the Philippine HealthInformation Network (PHIN) published theresults of a comprehensive assessment ofthe Philippine health information system11,with leadership of the DOH and the supportof the World Health Organization (WHO)Health Metrics Network (HMN). The HMNassessment framework uses a top-down,national-level approach based on a series ofworkshops that use focus group discussionsto reach group consensus on scoresassigned to a series of health informationsystem assessment criteria.

The assessment identifies the FHSIS as the major source of data for the DOH. Yet nearly 60%of participating nurses and midwives cited a lack of FHSIS form supplies and noted theduplication of entries on different forms. Provincial and regional coordinators noted problems inthe timeliness, completeness, and quality of data submitted to the FHSIS.

8Philippine Department of Health. Strengthening the Field Health Services Information System, Grand

Villa, Laguna, May 16-18, 2007. DOH-NEC-PHSID July 2007.9 Jayasuria R. Health informatics from theory to practice: lessons from a case study in adeveloping country. MEDINFO95 Proceedings. Greenes et.al. (editors). IMIA 1995; pp 1603-1607.10

Tolentino H., Marcelo A., Marcelo P., and Marimba I. Linking Primary Care Information Systems andPublic Health Vertical Programs in the Philippines: An Open-source Experience. 2005. AMIA Annu SympProc. 2005; 2005: 311–315. [PubMed:http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1560490]11

The Philippines Health Information Network. Philippine Health Information System: Review andAssessment, February – Jul 2007. Health Metrics Network.

Exhibit 1. Diagram showing the relationshipbetween patient-level data, vertical health programreporting, and FHSIS reporting.

FHSIS

NotifiableDiseases

Registry / DiseaseControl

Maternal Care

Family Planning

Tetanus Toxoid

Child Care

Dental CareImmunization

Aggregated Data

Children at RiskInitiative (CAR)

ChildhoodDiarrhea andDehydration

(CDD)

Maternal andChild Health

(MCH)

NationalTuberculosis

Program (NTP)

Family Planning

ExpandedProgram on

Immunization(EPI) and Under

Five Clinic

Vertical Programs

Patient Records

Aggregated Data



The PHIN assessment highlights the general lack of coordination, standards, andinteroperability among the multitude of separate, disconnected systems used to collect,manage, and report health information. The assessment calls for a comprehensive plan andnational standards to facilitate the integration of system components and reduce duplication ofeffort. It envisions a decentralized network of harmonized information system components builtby different agencies using a common set of standards. It recommends involving LGUs inredesigning the FHSIS to better meet local needs. It emphasizes the importance of increasingthe capacity of health workers to use health information. Finally, the assessment notes that fewRHUs have computers or Internet connectivity, and emphasizes the need for this infrastructure,but never mentions the use of electronic medical records at the point of patient care.

The remainder of this section provides an overview of FHSIS data collection, processing, andreporting, and examines the specific case of Tarlac Province.

2.1 FHSIS Data Flow

Exhibit 2 is a simplified diagram showing the flow of FHSIS data from health units to the nationalFHSIS annual report. Health units include barangay health stations, city and rural health units,and hospitals. Hospitals include provincial hospitals, district hospitals, military hospitals, andspecialized hospitals. Provincial and district hospitals are under the supervision of the provincialgovernment, while the municipal governments manage the rural health units and barangayhealth stations.

Barangay health stations and rural health units are the primary health care units in thePhilippines and provide the following health care services:

Information/education/counseling Well adolescent services Maternal and child health (MCH) services Family planning (FP) services Reproductive track infections, including HIV/AIDS and sexually transmitted infections (STI) Prevention and management of abortion complications (PMAC) Violence against women and children (VAWC) Mental health services Substance use/abuse Referral to higher level facility for unmanaged cases



Exhibit 2 A simplified diagram showing the flow of data in the Field Health Service Information System(FHSIS).

FHSIS Reporting

LGUHealth Unit

DOHRegionProvince

PHOLGU

CHO/MHO

Start

Consolidate datafrom paper

registers and enteron FHSIS forms

Review FHSISforms from RHUs

Is formcomplete &consistent?

Review form forcompleteness& consistency

Yes

Is formcomplete &consistent?

Enter data intoFHSIS database

Yes

Produce standardprovince-level

reports

Consolidateprovince-level

data

Produce standardregion-level

reports

Consolidateregion-level data

End

No

No

Produce standardnational-level

reports

Provide feedbackto RHUs

Sign and submitfor to PHO

Resolve dataquality problems

Maintain routinepatient recordsand registers

Resolve quality ofcare issues

Portion of the systemtargeted by the WirelessReach PhilippinesPartnership pilot project.

Portion of the systemaddressed by anelectronic medicalrecord system.

Monthly Quarterly



A barangay health station (BHS) is the smallest point-of-care facility in the public health system.It provides a wide range of primary care services and is staffed by rural health nurses andmidwives. Depending on size and location staffing may also include a medical technician, adentist, and a physician.12 In 2007, the most recent year for which national statistics areavailable, there were 16,219 barangay health stations in the Philippines.13 Each BHS servesfrom one to five barangays and is under the direction of a designated rural health unit.

A rural health unit (RHU) provides additional services beyond those provided by a barangayhealth station. These include simple out-patient surgical procedures, uncomplicated vaginaldeliveries, laboratory services, management of the side effects and simple complications arisingfrom contraceptive use, emergency services for mental / psychiatric cases and more advancedmental health services, and dental services. A city health unit (CHU) provides the same servicesas rural health unit, but is located in a city and may be more fully staffed. Depending on thesource consulted, there are between 1,800 and 2,300 rural health units in the Philippines.

Each RHU is normally staffed by one or two doctors, from one to four nurses, a medicaltechnician, a dentist, a dental aid, several midwives, and one or more non-technical supportstaff.

Each month each RHU aggregates data manually from paper registers and enters the totalsonto standard FHSIS forms. RHUs also receive and aggregate data from the barangay healthstations that report to them. On average a RHU may supervise twenty barangay health stations.In cities an RHU may supervise many more.

Totals are reported to the FHSIS at the RHU level. Completed FHSIS forms are then submittedto city health officers (CHOs) and municipal health officers (MHOs), where they are reviewed forcompleteness and consistency. Any problems detected at this level are resolved directly withthe RHU. Once FHSIS forms have passed MHO review, they are signed by the MHO andsubmitted to the PHO. Forms are reviewed again at the PHO. Any problems that are detected atthis point are resolved through the relevant MHO. Once FHSIS forms pass PHO review, thedata are entered into the FHSIS database application by PHO personnel. Standard province-level and LGU-level reports are produced by the PHO. The consolidated data are thentransferred to the Regional Epidemiology Surveillance Unit (RESU) of the Center for HealthDevelopment (CHD) office, where they are combined with data from other provinces in theregion. Regional data are sent electronically to the DOH national office and are used to produceannual national FHSIS reports disaggregated by region, province, and city/municipality. Thefollowing section describes how this system works in practice in Tarlac Province.

12Health Service Protocol, Department of Health, Philippines. Accessed at

http://doh.gov.ph/ayhd/htm/bhs.htm on 11 April 2009.13

Field Health Service Information System, Annual 2007, National Epidemiology Center, Department ofHealth, Manila



2.2 FHSIS Reporting in Tarlac Province

Exhibit 3 shows the location of Tarlac Province inRegion III, Central Luzon. The USAID HealthGovproject is carrying out several activities in Tarlac,including providing technical assistance for thedevelopment of the Province-wide HealthInvestment Plan (PHIP). In March 2008 membersof the USAID HealthGov project team visitedTarlac Province to begin assessing capacity andconditions at the province and LGU level, as wellas data quality and reporting problems of theFHSIS.

The population of approximately 1.3 millionpeople distributed over 512 barangays is servedby 187 barangay health stations14, 36RHUs/CHUs, two (2) district hospitals, one (1)community hospital, one (1) army stationhospital, and one (1) provincial hospital. Onaverage an RHU supervises five (5) barangayhealth stations. Eight (8) of the 36 RHUs havebirthing rooms. These facilities are staffed by atotal of 35 doctors, 27 dentists, 67 nurses, 200midwives, and other supporting health workers.The average number of persons served by eachRHU and its barangay health stations isapproximately 37,000. While some RHUs are inmountainous areas far from Tarlac City, most have a fairly reliable supply of electricity andmobile cellular phone service. Nearly all nurses and midwives have cell phones15.

Exhibit 4 shows the existing flow of data into the FHSIS from Tarlac Province. Each monthnurses and midwives in each RHU are responsible for consolidating data manually from RHUpaper registers and recording the consolidated monthly figures on FHSIS data collection forms.RHUs also consolidate data from BHSs that report to them. These are submitted to City HealthOfficers/Municipal Health Officers (CHO/MHO) who submit them to the PHO.

The PHO reports that only 60% to 70% of the 36 RHUs submit completed FHSIS forms on time.The remaining 30% to 40% must be hounded for weeks until they submit their forms. Only 60%to 70% of LGUs submit FHSIS reports to the PHO on time. For municipalities not submitting ontime, reports are usually delayed by ten to fifteen days. Large distances between somemunicipalities and the provincial center cause some reporting delays. Problems with access to aservice vehicle, absence of computers for database processing, and insufficient travelallowances seriously affect the timely submission of FHSIS reports. The PHO reports that RHUsare asked to report the same statistic to the FHSIS, to provincial coordinators, and to variousvertical health programs, and often submit different values for the same data statistic. The PHO

14Unpublished data from the 2008 FHSIS. The Field Health Service Information System Annual 2007

report lists 437 barangays and 169 barangay health stations in Tarlac Province.15

Source: Dr. Ricardo Ramos, Provincial Health Officer.

Exhibit 3 Map showing the location of TarlacProvince in the Philippines.



also checks incoming forms for improbable numbers. The PHO must then reconcile these dataquality problems with the relevant RHU.

Exhibit 4. Pictorial diagram of the existing FHSIS data flow of data into the FHSIS fromTarlac Province.



Once data on FHSIS forms have passed these quality control checks, the PHO enters monthlytotals into Microsoft Excel spreadsheets, which are used to calculate quarterly and annual totalsfor entry into the FHSIS. If FHSIS reports are complete and on-time, it takes only a day for thePHO to encode the data, but reports are incomplete and often contain questionable data. Ittakes weeks for the PHO to resolve these problems with some RHUs.

Data are encoded into the FHSIS Microsoft Access database application by the PHO. Data onreportable diseases are encoded into the database weekly. Other data are encoded into thedatabase quarterly.

The Microsoft Access database application was originally developed and maintained by theDOH in Manila. It is now maintained by the DOH CHD-3 Region III Regional EpidemiologySurveillance Unit (RESU), since Region III added elements to standard FHSIS. Until March2008 the Global Fund is paid the salary of the FHSIS data encoder. The data encoder is nowpaid by the PHO. The PHO uses used or recycled computers. Technical support for thesecomputers is provided by the provincial hospital, which has a computer network. The PHO hasan Internet connection that can be used to transmit quarterly FHSIS data and reports to theRESU.

The RESU combines quarterly reports from the provinces and submits quarterly reports fromthe region to the DOH central office in Manila. The DOH publishes an annual FHSIS report.Delays in reporting at the BHS/RHU level ripple through the system, resulting in a data lag fordecision makers. Many decisions are therefore made using data that is at best three months oldand at worst more than a year old. The lack of timely access to information is most critical at thepoint of patient care where decisions directly affect lives. For example, postpartumhemorrhaging accounts for 17%16 of maternal mortality in the Philippines. RHUs withmaternities, and even hospitals that need blood urgently for transfusions, do not have access tocurrent information on available blood bank resources.

Improving the health information system, specifically FHSIS reporting and data quality havebeen part of discussions between the USAID HealthGov technical assistance team and TarlacProvince concerning the Province-wide Health Investment Plan (PIPH). In consultation with theUSAID HealthGov project, the Tarlac PHO has established the objective of creating anelectronic health registry for the entire Province. While Tarlac is a pilot site for the Electronic TBRegistry Project of Global Fund, the use of information technology to manage health informationin the Province is generally low. The USAID HealthGov Year 2 Work Plan includes projectassistance to Tarlac Province in identifying tools, processes and other support systems that willhelp health personnel address problems in delayed reporting, analysis and utilization of healthinformation for planning and monitoring and evaluation.

16Philippine Department of Health, 12 February, 2008. Accessed at

http://www.doh.gov.ph/kp/statistics/maternal_deaths on 8 April 2009.



3 Problem Analysis

3.1 The National HMIS Pyramid

The health management information system (HMIS) problems described in previous sectionsare not unique to the Philippines. National health management systems are typically designedfrom the top down to meet the needs of national-level decision makers. Exhibit 5 shows a typicalpyramid diagram used to illustrate the increasing aggregation of data as they are reported upthrough this hierarchy to the national level. Similar diagrams can be found in many HMIS papersand reports. The HMN assessment framework reflects this top-down orientation, since thedriving interests are often at the internationaland national level. In these hierarchicalsystems data are periodically collected andconsolidated at each level, and are thenreported to the next higher level in theorganizational hierarchy. This is often donequarterly. Data are normally encoded intocomputerized spreadsheets or databases atthe district, or province level. Reporting todecision makers at each level is often verylimited, and in many countries results only ina single annual statistical yearbookproduced at the national level. Feedbackloops in these systems are often minimaland may be limited to quarterly or evenannual reports that contain aggregate data,without analysis or interpretation.

3.2 Manual Record Keeping Systemsat the Point of Patient Care

Most data in these systems originate in facilities providing patient care. Record keeping systemsin these facilities are normally based entirely on paper records. These include individual patientfiles and a multitude of registers. Unique patient identifiers are often created separately by eachfacility, and sometimes by different treatment programs within the same facility. Since patientidentifiers and records are normally accessible only within each facility, it is nearly impossible totrack patients who are treated at different facilities or for clinicians in one facility to accessimportant patient records that may exist in other facilities. Within a facility patient information isscattered across numerous paper registers that are time consuming to maintain and make itdifficult to find and cross-reference patient information. As the patient load increases, recordkeeping systems tend to deteriorate under pressure as clinicians focus on only the mostessential tasks. Manual record keeping systems may deteriorate more rapidly than well-designed electronic record keeping systems, since manual systems are normally much lessresponsive to the information needs of clinicians and require more effort to maintain.

Manually aggregating data from paper records for monthly and quarterly reporting is timeconsuming and takes time that otherwise could be devoted to patient care. Overlapping datareporting demands from numerous vertical health programs increase the reporting effort.According to the WHO, after about 500 patients paper systems at the clinic level become

Exhibit 5 A typical national health informationsystem pyramid diagram.

Point of patient care

District

Province

NationalFeedback

Feedback

Feedback Reporting

Reporting

Reporting



unmanageable.17 Paper records accumulate at the point of patient care. Storage spacebecomes a problem, records begin to deteriorate, and historical records become difficult andeventually impossible to locate. Simple cross sectional analysis is possible, but longitudinalanalysis of trends in health status and the quality of care is virtually impossible.

The information feedback loops indicated in Exhibit 5 are rarely implemented, particularlyfeedback to the point of patient care. Since there is rarely any feedback to clinicians that wouldhelp them improve the quality of care, there is little if any reason for clinicians to be concernedabout the accuracy or timeliness of their reporting. Clinicians have been known to “manufacture”data simply to comply with reporting requirements in the least amount of time. In reality theentire pyramid shown in Exhibit 5 rests on a busy rural health nurse who is more concerned withtreating patients than in the accuracy and timeliness of required monthly reporting that does nothelp her in her daily work.

3.3 Electronic Medical Record Systems

Electronic medical records (EMR) have the potential to better meet information needs at thepoint of patient care while providing higher quality data to higher level decision makers. Usingan EMR system, clinicians enter patient data directly into a computerized database. Patient datacan therefore be accessed quickly and easily to help improve patient care, can be shared byclinicians working in various departments within the same facility, and, usingtelecommunications, can even be shared securely among health care facilities. This is usefulwhen patients visit different facilities for care, and can be used to refer patients electronically forspecial treatment. Since patient records are retained electronically, they take up little physicalspace, do not deteriorate, can be accessed easily when needed, and can be used easily forhealth surveillance and longitudinal analysis of the population and the quality of care. They canalso be used to by clinical care supervisors to coach clinicians and to monitor the results ofchanges in policies and protocols.

An EMR system provides direct and immediate feedback to clinicians who are the primarysource of most HMIS data. If it meets the daily needs of clinicians, it will be accepted andsustained. Clinicians are therefore motivated to ensure that data they need from the system arecomplete and accurate. An EMR can also save clinicians time by automating routine reportingand submitting reports electronically. The use of and EMR can therefore result in improvedtimeliness and quality of routine reporting to the HMIS.

The 2007 HMN-sponsored national assessment of the Philippine health information systemmakes no mention of electronic medical or patient records at the point of patient care. Ten yearsago most public health and development professionals would have considered EMRs to befeasible only in the most developed countries. Today there are several examples at varyingstages of maturity. In Sub-Saharan Africa these include the AMPATH18 Medical Record System(AMRS) in Eldoret, Kenya, the Zambian Electronic Medical Record System (ZEPRS)19 in

17Paper versus Electronic, an Interview of Chris Bailey, World Health Organization. Making the eHealth

Connection, Rockefeller Foundation Bellagio Center, 2008. Accessed athttp://www.youtube.com/watch?v=d6eub8Lc6Tg on 11 April 2008.18

The Academic Model for the Prevention and Treatment of HIV/AIDS (AMPATH) is a project under theauspices of Moi University School of Medicine and Moi Teaching and Referral Hospital.19

RTI was instrumental in developing ZEPRS under a subcontract to the University of AlabamaBirmingham and with funding from the Bill & Melinda Gates Foundation.



Lusaka, Zambia, SmartCare20 in Zambia, and the Baobab HIV Treatment system (BART) inMalawi. In the Philippines these include the Community Health Information Tracking System(CHITS). The most mature of these efforts are seven and eight years old. Four are electronic-first21 systems. Two are implementations of OpenMRS22, an effort to develop a flexible,community supported EMR using free and open source technology.

These efforts have produced important innovations and lessons in appropriate technology, localcapacity building, using EMR data to improve the quality of care, and strategies for sustainingthese systems. This project should build on the lessons learned and technologies developedthrough these existing efforts to ensure that the resulting system has the followingcharacteristics:

Meets the needs of clinicians Can be sustained by LGUs Can be interfaced with the FHSIS and other health information system components Can be scaled to meet emerging needs Has a broad base of national and international support

The following sections review the results of several of these efforts and how they might benefitthis project.

3.4 The Zambian Electronic Perinatal Record System (ZEPRS)

RTI worked with the University of Alabama Birmingham (UAB), Lusaka Urban Health District,and Center for Infectious Disease Research in Zambia (CIDRZ) to design and implement theZambian Electronic Perinatal Record System (ZEPRS). Launched at the beginning of 2006,ZEPRS is used by 24 clinics and one referral hospital in Lusaka to manage care for more than270,000 perinatal patients and 96% of all births in Lusaka, a city of more than one millionpeople.23

ZEPRS was designed with significant input from a team of American and Zambian clinicians. Itis designed specifically for perinatal care, but can be modified without reprogramming to adaptto other needs. ZEPRS guides clinicians through clinical protocols and uses intelligent “system-generated outcomes” to alert them automatically to conditions that require special attention,including patient referral. ZEPRS includes an electronic patient referral system.

Perhaps the first and largest electronic-first medical record system in Sub-Saharan Africa,ZEPRS has been used in more than three million patient encounters. It includes a largelongitudinal patient record database and an electronic patient referral and tracking system. The

20SmartCare was initiated in 2004 with support from the CDC in Zambia.

21In electronic-first medical record systems, clinicians retrieve data from and enter data to the electronic

system during the course of patient care. In paper-first medical record systems clinicians retrieve datafrom paper reports and enter data on paper forms during the course of patient care. The data are thenentered into the electronic system later, often by dedicated data entry personnel.22

AMRS is an implementation of OpenMRS. BART uses the OpenMRS data model, but has its own userinterface developed using Ruby on Rails and other technologies. AMRS is the oldest OpenMRSimplementation in Africa. BART is the largest implementation of the OpenMRS data model in Africa.23

See http://en.wikipedia.org/wiki/ZEPRS and www.rtidemo.org/front/node/113 for more informationabout ZEPRS.



large shared patient record database has proven invaluable for health surveillance, monitoringthe results of health care interventions, and measuring improvements in the quality of care. Thepatient record database is being used to produce standard reports for the national HMIS and forthe US President’s Emergency Plan for AIDS Relief (PEPFAR). Exhibit 6 is a photo showingnurses learning to use ZEPRS to refer patients electronically to the University Teaching Hospitalin Lusaka.

RTI has continued to enhance the free andopen source EMR software developed forZEPRS. The software, now called zcore24, iseasy to install, flexible, and scalable. It runs onWindows or Linux-based computers and hasmodest hardware requirements. It can beinstalled on a single computer and sharedamong several networked computers in thesame facility. It can transmit data to other sitesover intermittent connections, including existingmobile phone networks. In addition to beingused by the large perinatal system in Lusaka,Zambia, the software, which will remain freeand open source, is being used by healthcenters in Nairobi, Kenya, to manageantiretroviral (ARV) pharmaceutical suppliesover the Telkom Kenya mobile phone network.RTI is currently adapting the software tomanage treatment and care of rape survivors in South Africa.

ZEPRS has proven that an open source electronic-first medical record system can scale up tohundreds of thousands of patients and can be sustained for years. The zcore software that hasemerged from ZEPRS offers the following features that may be useful for this project:

Patient search box and results listing on home page Guides clinicians through appropriate procedures automatically Alerts clinicians automatically when follow up actions are needed Enables clinician to add comments to records Standard web interface practices such as automatic input validation for data Works in networked and stand-alone25 mode Stand-alone version can synchronize with a data center over intermittent connections Easy configuration of forms/fields by non-programmer Use of software technologies that help new programmers get up to speed quickly Easy installation for non-technical users Works on Windows and Linux computers Free and open source software

However, in its current configuration zcore uses its own data model. It does not use a datamodel that has widespread international support. The current version of zcore also includes

24See www.rtidemo.org/zcore for more information about zcore.

25Can be installed and operated easily on a single computer without requiring a special server.

Exhibit 6. Nurses in Lusaka, Zambia, using theZambian Electronic Perinatal Record System tomanage patient records.



reports, but does not include a powerful and flexible reporting module. OpenMRS, which isdiscussed in the following section, offers a widely recognized data model and a powerfulreporting tool.

3.5 OpenMRS

OpenMRS is a collaborative open source project to develop software to support the delivery ofhealth care in developing countries. It is the most widely recognized free and open sourceelectronic medical record system. OpenMRS grew out of the critical need to scale up thetreatment of HIV in Africa, but was also conceived as a general purpose electronic medicalrecord system that could support the full range of medical treatments. The system is designedfor very resource poor environments. New data items, forms and reports can be added withoutprogramming. It is intended as a platform that many organizations can adopt and modifyavoiding the need to develop a system from scratch.

OpenMRS is based on a "concept dictionary" that describes all the data items that can bestored in the system such as clinical findings, laboratory test results or socio-economic data.This approach avoids the need to modify the database structure to add new diseases forexample, and facilitates sharing of data dictionaries between projects and sites. The modularstructure of OpenMRS allows the programming of new functions without modifying the corecode. OpenMRS is web based but can be deployed on a single laptop or on a large server.

OpenMRS was deployed first in Eldoret, Kenya in February 2006, followed by the Partners inHealth hospital in Rwinkwavu, Rwanda in August 2006 and Richmond hospital, South Africalater that year. OpenMRS is in use in at least 14 countries mostly in Africa. Most of theseinstallations are small in terms of numbers of patients, but a few manage more than 10,000patient records, and the oldest, in Eldoret, Kenya, is used to manage more than 60,000 patientrecords.

The University of the Philippines is working with the Massachusetts Institute of Technology(MIT) and other partners to pilot test MocaMobile, a mobile phone based remote diagnostic andscreening application, in conjunction with OpenMRS.

OpenMRS offers the following features that may be useful for this project:

A proven data model based on an extensive concept dictionary A structure that allows additional modules to be added to the core functionality Can be deployed on a single computer or in a networked configuration Wide-spread recognition and a broad based international support community Works on Windows and Linux computers Free and open source software

Unfortunately the current version of OpenMRS is difficult for non-technical users to install andconfigure. It has also been designed for data entry from paper forms. It does not lead usersthrough clinical protocols, alert clinicians automatically to take needed follow-up actions, orenable clinicians to refer patients to other facilities electronically. Like ZEPRS and zcore, theBaobab Health Partnership has also designed an EMR to lead clinicians through health careprotocols automatically. They have also demonstrated the value of using touch screen



workstations and bar coding to speed data entry and lower operating costs. This system isdiscussed in more detail in the following section.

3.6 Baobab Health Partnership

Baobab Health, a Malawi-based non governmental organization, has been addressing theHIV/AIDS crisis in that country for the past eight years by applying medical informatics principlesto a resource-poor setting. The core of Baobab’s approach is a simple “appliance” model thatuses easy-to-use touch screen clinical workstations at the point of patient care. This systemefficiently and accurately guides low-skilled health care workers through the diagnosis andtreatment of patients according to national protocols. The system also captures timely andaccurate data that is used by healthcare workers during patient visits to supplement decisionmaking. The data are aggregated and usedat a national level for policy making andanalysis. This technology-dependentapproach has required both hardware andsoftware innovations, including alternativeenergy approaches, intuitive touch screen-based user interfaces for users with nocomputing experience, and low-costinformation appliances that are significantlymore robust in harsh environments thantraditional computers. Exhibit 7 is a photoshowing a worker using the touch screensystem to register a patient. To date morethan 800,000 patients have been registeredand over 18,000 receive HIV care facilitatedby a Baobab system.

The Baobab system offers the followingfeatures that may be useful for this project:

A proven touchscreen “appliance approach for clinical workstations that is easy to use,speeds data entry, and reduces operating costs

Use of the widely recognized OpenMRS data model Use of bar coding to speed patient identification Use of easily produced paper patient “passports” for some record portability Innovative alternatives to electrical power from the utility grid A proven system for developing local technical development and support capacity Free and open source software

At least some of these innovations could be adapted for use in the Philippines. The EMRsystem discussed in the following section is already in use in the Philippines and can contributevaluable experience and insights into the design of this project.

3.7 The Community Health Information Tracking System (CHITS)

The Community Health Information Tracking System (CHITS) is an electronic-first electronichealth record system designed for public health centers in the Philippines. It was developed bya team lead by Dr. Herman Tolentino of the Medical Informatics Unit of the National Telehealth

Exhibit 7. Registering a patient using the Boababtouch screen system.



Center, College of Medicine, of the University of the Philippines. CHITS is the flagship electronicmedical records project of the National Telehealth Center.

CHITS was first implemented in 2004 through grants from the Canadian InternationalDevelopment Research Centre: International (IDRC) Panasia ICT Project and the UNDP. Afterthree years CHITS is still working in Lagrosa and Malibay health centers in Manila. While theproject appeared to stall after the end of the initial IDRC project in 2005, CHITS has gainedincreasing interest among LGUs in 2007 and 2008, and the number of deployments isincreasing. To date CHITS has been installed in a total of 18 health centers.

Similar to OpenMRS, CHITS has been implemented as an open source web-based applicationthat can be installed on a single computer or used in a networked configuration. The softwarewas built on a framework that makes it easy for programmers to add new modules to thesystem. The software can be use to generate many of the standard monthly reports required bythe FHSIS. CHITS incorporates several international standards, including the WHO InternationalClassification of Diseases (ICD-10)

The National Telehealth Center has developed a system for deploying CHITS in LGUs thatincludes a readiness checklist. The National Telehealth Center notes that Inter-Local HealthZones (ILHZ) might lower the deployment and operating costs of and electronic medical recordsystem by sharing resources.

The CHITS system offers the following features that may be useful for this project:

Support of the National Telehealth Center A well-developed training and certification system Significant experience introducing an EMR into health centers in the Philippines At least two reference installations in the Philippines An understanding of EMR integration with vertical health programs in the Philippines

The CHITS software is currently being maintained by a single developer. In its current version itis not easy to install and could be improved technologically. It does not guide clinicians throughclinical protocols or include intelligent system-generated outcomes or alerts. It also does notinclude a data transmission or electronic referral system. Like zcore, it uses its own data modelrather than a more widely-recognized data model such as OpenMRS. Also, while CHITS hasachieved some success and gathered increasing interest and support from LGUs, it still lacksthe official endorsement of the DOH.

However, and perhaps most importantly, CHITS has been designed in the Philippines to meetlocal needs and considering local culture. It incorporates important lessons learned, has beensuccessfully deployed and sustained, is accompanied by a training and certification program,and is a sound technical platform on which to build. Technical upgrades and innovations fromother international projects could be incorporated into the software over time.

3.8 Applicability to the Philippines

The examples discussed in previous sections demonstrate the feasibility of electronic records inless developed countries. Each of these examples highlights important innovations andstrategies. Since several of these examples are from Africa, it is also important to recognize



unique characteristics of the Philippines that should be considered in developing projectstrategy. These include the following:

A landmass consisting of more than 7,000 islands A devolved public health care system in which LGUs are responsible for managing and

providing local public healthcare services. The concept of Inter-Local Health Zones (ILHZ)26 that enable LGUs to band together to

achieve health reforms through integrated governance, management, financing, resourcesharing.

A two-tier primary health care delivery system consisting of barangay health stations andcity and rural health units.

Rapid turn-over of clinicians due to emigration. Mobile phone coverage for more than 90% of the population. Excellent access to information technology in major cities.

Several of these characteristics suggest that some technologies and strategies that have provensuccessful in Africa may also be useful in the Philippines. They also suggest that opportunitiesfor scale up and sustainability are better in the Philippines than in many African countries. Anapproach that builds on the knowledge, experience, and momentum of CHITS, including thetraining and certification system, and over time injects some of the strongest attributes of zcore,OpenMRS, the Baobab Health Partnership, and other related efforts, could meet the objectivesof this project and build a firm foundation for scale-up and sustainability in the Philippines.

3.9 The Roles of National and International Organizations

Efforts to introduce electronic medical records also highlight weaknesses and gaps ininteroperability between systems and weaknesses in national standards. This includes whethernational governments have developed and maintained essential national coding standards,such as patient and facility identifiers, minimum data sets, and national data codebooks. Theseexamples also raise questions concerning the capacity of national governments to fostereffective scale-up, and highlight the failure of donors to support such critical elements that cutacross vertical donor assistance programs. The devolution of health services in the Philippineshas changed the roles of national and local governments with respect to health informationsystems.

A 2003 study concluded that the devolution of health services in the Philippines resulted in abreakdown in management systems between levels of government and weakening of thepatient referral system.27 The 2007 review and assessment of the Philippine national healthinformation system conducted through the Philippine Health Information Network (PHIN)28

emphasizes the pivotal role to be played by the DOH, National Statistics Office, and theNational Statistical Coordination Board in developing, maintaining, and promoting the use of

26An ILHZ is a well-defined geographic area where individuals, communities and all other health care

providers participate in providing quality, equitable and accessible health care with inter-LGU partnershipas the basic framework.27

Gundy J., Healy V., Gorgolon L., Sandig, E., Overview of devolution in the Philippines. TheInternational Electronic Journal of Rural and Remote Health Research, Education, Practice and Policy,2003.28

The Philippine Health Information Network includes national government agencies and internationalorganizations and donors



technical standards that facilitate the interoperation of various health information systemcomponents. The need for maintaining such coding systems at the national level becomesapparent as efforts increase to connect various health information system componentselectronically. The need for such national standards in the Philippines was recognized as earlyas 1999.29

Under FOURmula ONE (F1) for Health, the DOH established a Unified Health ManagementInformation System website to disseminate information concerning health information systemcomponents developed by the DOH.30 Work towards establishing a coherent national levelhealth information system received new emphasis with the establishment of PHIN in 2007. Theobjective of PHIN is to develop a coherent national health information system road map to guidelocal stakeholders working to develop health information systems that meet local needs and thatcould contribute valuate data for use by decision makers at the regional and national level.Exhibit 8 is a DOH diagram of the national health information system strategic framework. In theabsence of such guidance and coordination, stakeholders at all levels will continue to developparallel and overlapping systems that cannot interoperate as components within a coherentnational health information system. The diagram in Exhibit 8 appears to imply that the flow ofstandards is down and the flow of data is up, since all data beneficiaries appear at the top of thediagram. It is important to recognize that beneficiaries also include clinicians in barangay health

29The Standards for Health Information in the Philippines (SHIP-DE1-19990712), The Study Group on

Standards for Health Information, National Institutes of Health, University of the Philippines, Program onComputer Research in Information Technology (CRIT), 1999.30

Accessed at http://umis.doh.gov.ph/uhmis/index.php?option=com_frontpage&Itemid=1 on 1 May 2009.

Exhibit 8. Department of Health diagram of the Philippine National Health Information System StrategicFramework.

De

pa

rtm

ent

of

He

alth

Serv

ice

Pro

vid

ers



stations, RHUs, and other health units shown at the bottom of the diagram. An EMR system isdesigned to provide useful information directly to these beneficiaries, while also improving thetimeliness and quality of data reporting to beneficiaries at higher levels.

Meeting the challenge of treating clinicians as primary data users is essential to providing betterquality data to national level decision makers. Meeting the challenge of providing essentialinteroperability standards and helping to coordinate the work of external health informationsystem developers are necessary to produce an integrated national health information system.Several international organizations have been formed as forums for public health and healthinformatics practitioners to share information about meeting these challenges.

The Global Partnership for Public Health Informatics (GPPHI)31 is a global effort to bringtheorists and implementers together to meet these challenges internationally. Many GPPHIpartners are working to advance efforts to develop and deploy EMRS that have a direct impacton the quality of health care while providing better quality and more timely data to nationalhealth management information systems. While the GPPHI has succeeded in sharpening focuson some of these issues, a significant gap remains between high-level theorists and standardsbodies, such as the WHO, and those designing and implementing systems on the ground. RTIhas joined the GPPHI to help contribute to sustainable solutions to these challenges.

USAID can play an important role in the Philippines by helping to support an effort to develop ascalable and sustainable electronic medical record system that can meet the needs ofthousands of barangay health stations and rural health units and be supported by LGUs and theDOH. This system should build on lessons learned and technologies developed in thePhilippines and in other countries. It should be used as a catalyst to encourage the developmentof national coding standards that facilitate the interoperability of health information systemcomponents and the secure flow of data between systems. The resulting system shouldimprove the quality of care and dramatically improve the quality and timeliness of data availableto decision makers at all levels of the public health care system.

4 Project Objectives

This project will achieve results in support of USAID Strategic Objective 3 (SO3), which is asfollows:

USAID SO3: Improved Family Health Sustainably Achieved.

Specially, this project is targeted at producing better quality and more timely information forhealth planning and budgeting, and will support HealthGov activities designed to better integratethese functions into local governance. It is designed to engage pilot LGUs and at least one localtechnical assistance provider organization to help improve the quality of public health services.Finally, it aims to institutionalize a multi-stakeholder coordination mechanism at the provinciallevel for participatory planning, leveraging resources, and sharing best practices.

This project will directly support the following HealthGov Intermediate Result (IR)

31http://www.gpphi.org/



IR 1.1: Strengthening LGU Management Systems.

The HealthGov Year 2 Work Plan includes project assistance to Tarlac Province targeted atachieving this intermediate result. This includes helping to identify tools, processes and othersupport systems that will reduce delays in reporting and improve the analysis and utilization ofhealth information. These measures are needed to help LGUs to improve their ability to useHMIS information to diagnose priority problems. The Wireless Reach Philippines Partnership fitswithin this component of the HealthGov Year 2 Work Plan. It will contribute to HealthGov IR 1.1by helping by improving the timeliness and accuracy of data reporting to the FHSIS frombarangay health stations and rural health units.

Projects supported by Qualcomm’s Wireless Reach initiative must meet the following objectives:

Showcase Qualcomm technology Involve partners including a local 3G operator and a non-governmental organization (NGO)

to manage the project Meet a community need Be in line with the local government’s Information and Communications Technology (ICT),

education, health care, environmental and/or other relevant policy goals Include a sustainability plan for continuation of the project after funding ends

In addition, Wireless Reach projects are intended to enhance Qualcomm’s image andstrengthen Qualcomm’s customer relationships to expand the market for Qualcomm’s advancedwireless telecommunication technologies.

This Wireless Reach Philippines Partnership project has been designed to contribute to theresults of the USAID HealthGov project and to meet the objectives of the Qualcomm WirelessReach initiative. Exhibit 9 shows an illustrative project results framework for the Wireless ReachPhilippines Partnership.

Exhibit 9 Pictorial diagram of an illustrative project results framework.

The solution developed and pilot tested by this project should contribute to meeting the healthinformation needs of decision makers. If this system is scaled up, it should improve the qualityand timeliness of FHSIS data at provincial, regional, and national levels. Time and fundingconstraints on this project limit it to developing and testing a solution within a few RHUs.However, the project should lay a firm foundation that can be scaled to support improved data



management, use, and reporting from health units throughout the country. Exhibit 10 describesthe benefits of such a system to decision makers at various levels

Exhibit 10. Table of project benefits to decision makers.

Decision Makers Benefit

Clinicians in Barangay Health Stations andRural Health Units (BHS/RHU)

Clinicians have quick access to patient information Clinicians are guided through patient care protocols Clinicians are alerted automatically to conditions that

require follow up or referral Patient referral information can be transferred

electronically Aggregate information from barangay health stations

can be entered for analysis and reporting FHSIS monthly and quarterly reports are generated

automatically Reports are transmitted electronically Time saved can be reallocated to patient care

City/Municipal Health Officers (CHO/MHO) Reports are received on time and in electronic form Data from rural health units do not need to be encoded

from paper forms Data can be preserved and analyzed at the barangay

health station level Data can be analyzed immediately Data can be analyzed at the barangay level Data are aggregated automatically for FHSIS reporting FHSIS monthly and quarterly reports are generated

automatically Reports are transmitted electronically

Provincial Health Office (PHO) Reports are received electronically and on time Data from city/municipal health officers do not need to

be encoded from paper forms Data can be preserved and analyzed at the barangay

health station level Data can be analyzed immediately Data are aggregated automatically for FHSIS reporting FHSIS monthly and quarterly reports are generated

automatically Reports are transmitted electronically

Regional Epidemiology Surveillance Unit(RESU)

Reports are received electronically and on time FHSIS quarterly reports are generated automatically Data can be received and analyzed at more frequent

intervals (e.g. monthly) Reports are transmitted electronically

Department of Health (DOH) Reports are received electronically and on time FHSIS reports are generated automatically FHSIS data can be made available at the LGU level,

and even at the health unit level Data can be received, analyzed, and published at more

frequent intervals (e.g. quarterly or even monthly)



Many of the benefits listed in Exhibit 6 will only be realized when most health units are able tomanage and report data electronically. Pilot RHUs will benefit directly if this pilot project issuccessful. The PHO will benefit if the system is subsequently scaled up to most RHUs in theprovince. The region will benefit if the system is deployed to other provinces in the region, andthe DOH will benefit if the system is adapted by most regions of the country. Therefore astrategy that offers LGUs an affordable, locally sustainable system endorsed by the DOH isfundamental to ultimately achieving national-level results. The Qualcomm Wireless ReachPhilippines Partnership project is the first step in achieving this goal. This project is designed todemonstrate that this can be done by building on existing open source software and Qualcomm3G wireless technology. The following section describes the proposed solution in more detail.

5 Proposed Solution

This project will help a local partner to use existing free and open source software to meet theroutine record-keeping needs of RHUs in the Philippines and to use Qualcomm 3G wirelesstechnology to transmit data over an existing mobile phone network from RHUs to the PHO tomeet the routine data reporting requirements of the FHSIS. The solution consists of thefollowing three major components:

1. An electronic medical record system for use in RHUs2. A system for transmitting FHSIS reporting data from RHUs to the PHO3. A system that enables the PHO to receive data electronically from RHUs for analysis

and reporting

Exhibit 11 shows how these three major components relate to and are integrated with FHSISreporting. Compared with Exhibit 4, which shows the existing FHSIS reporting system in TarlacProvince, the differences shown in Exhibit 11 are significant. Each of the three components ofthe solution is discussed in more detail below. It should be noted that this general configurationmay be modified to meet needs and challenges that emerge during the pilot project.



5.1 Electronic Medical Record System for RHUs

As shown in Exhibit 11, clinicians in RHUs will maintain patient records electronically usingsome type of computer.32 This system will provide immediate and direct feedback to clinicians,guiding them through clinical protocols and alerting them to conditions that require follow up orreferral. This system will eliminate most of the problems associated with maintaining thisinformation using paper records, and will eliminate the time consuming, labor intensive task ofmanually compiling monthly FHSIS reports. This system will not entirely eliminate the need forpaper in RHUs Experience on similar projects indicates that a paper patient summary record or“patient passport” may facilitate patient identification, provide some patient portability betweenfacilities, and provide some measure of backup for the electronic system.

32The specific type of computer will be selected in the design phase, but could be a low-power computing

appliance similar to the approach taken by the Baobab Health Partnership in Malawi. Experienceindicates that this could reduce initial costs, electrical power requirements, and operating cost, as well asimprove data security.

Exhibit 11. Pictorial diagram showing FHSIS data flow with an electronic medical record system.

FHSIS Reporting

LGUHealth Unit

DOHRegionProvince

PHOLGU

CHO/MHO

Monthly Quarterly

Electronic medicalrecord system

Start

Data availableimmediately in PHO

database

End

Health unit-level datatransmitted over 3G

mobile phone network

Data availableimmediately via Web-

enabled database

Quarterly reportsproduced at LGU and

Province level

Quarterly reportscollected from provinces

at LGU and Provincelevel

Annual report producedat region, province, and

city level

Portion of the systemtargeted by the WirelessReach PhilippinesPartnership pilot project.



A good electronic medical record system is designed to guide clinicians through procedures thatinclude the following:

Locating a patient record Registering a new patient, including assigning a unique patient identifier Updating patient demographics and contact information Reviewing and updating patient medical history, status, and outstanding problems Recording patient vital signs Maintaining patient information on family planning method acceptance and adherence Recording patient data for routine antenatal visits, including procedures, such as

ultrasound Recording laboratory test requests and results, including HIV/AIDS status and CD4

counts Maintaining patient records of disease diagnosis, including diseases that require the

notification of higher authorities (reportable diseases) Maintaining patient records for antiretroviral therapy Dispensing pharmaceuticals Recording and verifying immunizations Recording and reporting reportable diseases Maintaining records for maternity problem and labor visits, including use of the WHO

partograph during delivery Recording essential post-delivery patient and infant summary data Recording other patient treatment, including clinical notes Maintaining electronic links between mother and child records Maintaining weight and grow records for infants and children Managing patient appointments, including appointments for perinatal care and ARV

treatment Referring patients to another facility Generating standard reports for health and health care surveillance, and as required for

the HMIS (FHSIS) and special vertical programs, such as HIV/AIDS, malaria, andtuberculosis

Other functions that can be added to such a system include the following:

An electronic referral system that transmits patient information automatically to referralfacilities and tracks patient referrals

Integration with an electronic laboratory information system, enabling laboratory testresults to be entered into patient records automatically

A patient notification and reminder system using data communication over the mobilephone network

A system that enables community health workers to collect data using mobile phonesand transmit these data to the patient record database using the mobile phone network

A telemedicine system that enables nurses in remote health units to consult withphysicians located in hospitals, and for remote physicians to access patient data

Point of care testing modules to demonstrate test performance, document testinterpretation, and guide post-test counseling.



Medication adherence modules to guide health providers and their clients through thedevelopment of individual adherence plans, and provide visual feedback of biologicaloutcomes.

Health promotion modules to guide health providers and their clients through briefeffective behavior change counseling.

Designing, developing, and testing an electronic medical record system is an enormous task. Itincludes special considerations, such as patient privacy, data security, and data backup.Clinicians must be involved at every phase of design, development, and testing to ensure thesystem meets their needs. The resulting system must meet the needs of clinicians or they willactively resist rather than readily adopt it.

5.1.1 Building on Existing Systems

The Qualcomm Wireless Reach Philippines Partnership does not have the resources to developsuch a system from the beginning during the twelve-month pilot project. Instead, this pilotproject must adapt or build on an existing system. As described previously in this document,there are several existing open source electronic medical record systems that could be adaptedto meet the needs of RHUs. Also, this pilot project may not have the resources to implement allof the functions listed above. Functions may need to be prioritized and implemented based onwhether the contribute data to the FHSIS. The underlying software architecture, however,should support the implementation of other functions as additional resources become availablefor development, testing, and deployment. The specific electronic medical record systemplatform and functions to be implemented under this pilot project will be selected based oninformation collected and discussions held with stakeholders by the project team during theirinitial trip.

As described in Section 3.7, significant effort has been invested in developing and adaptingCHITS to routine record keeping needs of health centers in the Philippines. To date the systemhas been installed in 18 health centers. The National Telehealth Center has developed a CHITStraining and certification program and a framework for deploying CHITS through LGUs. Whilethe software technology needs to be upgraded, and the system could benefit from manyinnovations introduced by zcore, OpenMRS, and the Baobab Health Partnership, CHITS is alocal foundation on which to build and already has some measure of local support andmomentum. As explained later in Section 12 of this document, adopting CHITS significantlyreduces the risk that the project will fail due to a major gap between technical conception andthe reality in RHUs.

The project will build on the existing CHITS software by adding the necessary datacommunications module to transmit data over the mobile phone network to the PHO. Theproject will also help to develop a longer-term roadmap for CHITS development beyond this pilotproject. These may include the following enhancements:

System generated outcomes Electronic referrals Use of touch screen displays Use of bar coding Integration of mobile phone data collection for community health workers Use of the OpenMRS data model



Adding these enhancements will incorporate innovations from other efforts (OpenMRS,ZEPRS/zcore, Baobab Health Partnership, MocaMobile, ComCare) that will make the systemeasier and more efficient to use, increase the positive impact of the system on the quality ofcare, enable the system to interoperate with other health information system components, andbroaden sources of technical support. The decision to use an open source software model forthis project is consistent with project objectives. The software will not and will never requireLGUs or anyone else to pay software licensing fees. Also, local technical assistance providersaround the country can collaborate with each other and the DOH to continue to enhance andsupport the software.

5.1.2 Engaging a Local Technical Assistance Provider

The Medical Informatics Unit of the National Telehealth Center, University of the Philippines,could work with the DOH to coordinate a growing network of local technical assistanceproviders. . These may be provincial or regional universities with computer science orinformation technology programs. The CHITS effort has already developed a plan to developregional CHITS “reference centers” in partnership with regional universities. For this pilot projectin Tarlac Province we selected Tarlac State University (TSU), which has a strong College ofComputer Sciences. This project will provide grant funding and technical assistance to TSU toupgrade the CHITS software. The most significant enhancement will be the ability to transmitroutine FHSIS reporting data to the PHO over the existing mobile phone network. TSU will carryout this work as part of the CHITS open source project and as a learning opportunity forstudents in the TSU College of Computer Sciences.

5.1.3 Introducing the Electronic Medical Record System into RHUs

In partnership with two (2) LGUs, this pilot project will introduce this electronic medical recordsystem on a single computer in each of four (4) pilot RHUs. The system will be designed so thatit can be expanded later within each health unit by adding computers, interconnecting them viaa wired or wireless computer network. These computers could be placed at various strategiclocations around the facility. For example, one computer might be placed at the point of patientregistration, another outside a patient examination area, and another in the pharmaceuticaldispensary. These computers would share a common patient record database via the local areanetwork within the health unit.

5.1.4 Collecting Data from Barangay Health Stations

The same system could be implemented in at least some barangay health stations, dependingon infrastructure, personnel training, and the ability of the LGU to support these installations.This project focuses on RHUs because they are more likely to have the infrastructure to supportan electronic system, they provide more advanced services, including in some casesmaternities, and they currently consolidate data from barangay health stations. Also, LGUs aremore likely to be able to support the introduction of electronic record keeping systems at thislevel, since there are far fewer RHUs than barangay health stations.

The collection of data from barangay health stations by RHUs is an issue that needs to beresolved. RHUs currently collect and aggregate these data monthly, adding them to their own inmonthly reporting. The PHO therefore does not have access to data at the barangay healthstation level. The electronic system can improve on this by enabling RHUs to enter data frombarangay health stations monthly. The system would retain the link between the data and each



barangay health station. This would enable the LGU and the PHO to analyze and report data atthe barangay health station level.

5.2 Transmitting FHSIS Reporting Data to the PHO

As shown in Exhibit 11, clinicians in RHUs will use the electronic medical record system togenerate FHSIS reports automatically. This will eliminate the labor-intensive and timeconsuming task of manually compiling monthly reports. The system will then transmit thesereports to a server at the PHO electronically over the existing mobile phone network using 3Gmobile phone technology. This will eliminate the need for reports to be transported physically tothe PHO. The following section explains 3G wireless technology and why it is important to thisproject and prospects for scaling this system nation-wide.

5.2.1 3G Wireless Technology

Initially, cellular phone technology simply replicated the traditional telephone experience outsideof the home or office. As cellular phone providers added more users to their network they beganusing digital technology to compress the sounds that were being transmitted wirelessly andrealize more capacity from their networks. A byproduct of using digital technology was the abilityto send short digital messages (SMS), which soon became a popular method of inexpensivecommunication. This progression from analog to digital represents the first two major phases ofcommercial wireless communications. 3G is the next generation (3G stands for ThirdGeneration) of wireless technology, and its focus is the efficient transport of all types of data, asopposed to simply voice communications. This means emails, digital photographs, video - prettymuch everything available via the Internet can now be transmitted over a 3G network.

Developing countries, including the Philippines,have embraced 3G technology. It has allowedthem to acquire first world communicationscapabilities without having to build a copper andfiber infrastructure, which is more expensive andcomplex to roll out. As a result, the Philippines,and many other places like it have effectivelyleapfrogged this time consuming and costlystep. In fact, because the marginal utility ofgaining communication capability is so muchhigher in developing countries than developed, itis commonplace to find developing countrieswith more advanced wireless networks thanmore developed countries. This is certainly truein the Philippines, where three competingwireless providers, Smart, Globe, and Sun havealready rolled out 3G technology. The UnitedStates, meanwhile is still in the process of rollingout 3G, partially because companies like AT&Tand T-Mobile had already invested in oldertechnologies and also because "broadband" data infrastructure already existed - even if it wasonly available to computers and not mobile phones.

33GSM Association.

Exhibit 12 Smart Communications mobilephone coverage in central Luzon.

33



As a result, the Philippines has a robust and capable communications network. For example,Exhibit 12 shows existing Smart Communications network coverage in central Luzon. Thisnetwork can be leveraged for many things, but this proposal aims to use it to improve reportingfrom RHUs. By using the 3G wireless network to both capture data at the point of patient careas well as provide data back to the caregiver, the project expects to improve the timeliness,accuracy and use of data at the rural health center level. Specifically the 3G wireless networkwill enable health data to move quickly and efficiently from health care provider up the provinciallevel and even back down again when appropriate. Because the 3G wireless network is widelyavailable in the Philippines, and because of the focus improving reporting to the national FHSISreport, we hope the project will be easy to replicate and relevant throughout the country.

5.3 Receiving Data Electronically at the PHO

As shown in Exhibit 11, the Tarlac PHO willreceive data transmitted by RHUs. Datatransmitted under this pilot project will consist ofFHSIS reporting data. In the future datatransmissions could include other useful datafrom and between health units, including, forexample, patient referral data. Datatransmissions will be received over the existingPHO Internet connection by a database serverprovided by the pilot project. These data canthen be made available to LGU decision makers,imported into the FHSIS database, and used togenerate quarterly FHSIS reports automatically.

Other countries have shown that even sensitivehealth data can be transmitted reasonablysecurely over 3G wireless networks. Exhibit 13is a photo showing a nurse in a health center inNairobi, Kenya. She is using a system developed by RTI to manage pharmaceutical suppliesand to transmit routine reports to the central warehouse over an existing 3G mobile phonenetwork. This pilot project will demonstrate the feasibility of this data transmission method in thePhilippines. This data transmission system could be expanded later to provide real-timeinfectious disease reporting and electronic patient referrals.

6 Relationships with other Systems

The recent national level assessment of health information systems in the Philippines highlightsthe need to improve coordination, standards, and interoperability among the multitude ofseparate, disconnected systems.34 The electronic medical record system to be pilot tested bythe Qualcomm Wireless Reach Philippines Partnership will help improve this situation bydeveloping an electronic medical record system for RHUs that connects to the FHSISelectronically. There are many other separate health-related information systems in the

34The Philippines Health Information Network. Philippine Health Information System: Review and

Assessment, February – Jul 2007. Health Metrics Network.

Exhibit 13. A nurse in Nairobi, Kenya, managespharmaceutical supplies electronically andtransmits reports to the supply warehouse overan existing 3G mobile phone network.



Philippines. These have been created at the national level, as well as at the regional andprovincial levels.

6.1.1 Information Systems Developed by the DOH

In addition to the FHSIS, the DOH has developed many other separate health informationsystems to meet various needs. The table shown in Exhibit 14 lists these systems. With theexception of the National Electronic Disease Surveillance System (NEDSS), which has beendeveloped by the US Centers for Disease Control (CDC), these software applications havebeen developed by the DOH. The FHSIS has been implemented nation-wide. Most of the othersystems have been pilot tested at a few sites, and some have not yet been deployed. Thesesystems use a wide variety of software technologies. A few can generate standard reports ortransfer data electronically to the FHSIS, but published documents indicate that most of thesesystems are self-contained.

Exhibit 14. Table of Philippine Department of Health information systems

Name of System Function Target Users Status

Dialysis LicensingInformation System

Automate application, inspection,license, and issuance functionsfor dialysis clinics

Health SystemAdministrative Managers

Hospital Operationsand ManagementInformation System(HOMIS)

Patient medical records,admitting, billing, cashier, PHIC,Medical records, wards,laboratory, pharmacy, outpatient,radiology, emergency. Alsopersonnel info system, LogisticsManagement info system, andelectronic New GovernmentAccounting System (eNGAS)

Hospital Clinicians andManagers

Installed andimplemented in forty-two(42) governmenthospitals. Mostimplemented only thePatient ManagementModule only due toinsufficient funds forcomputing infrastructure.

Health HumanResource InformationSystem

Maintains database of HHR skills,training, educational background,matching required competenciesto individual’s skills. Used tomonitor human resource andtraining needs and to identifygaps.

District Health Officer

Integrated Blood BankInformation System

Connects network of nationalblood centers to share a registryof blood donors and blood stockinventory

Hospitals, Red Cross,National Voluntary BloodServices

Not implemented

Infectious DiseaseData ManagementProject

Captures and analyzes data onthe incidence of tuberculosis (TB)and rabies in rural health units(RHUs). Uses a GeographicalInformation System for datavisualization and geospatialanalysis

District Health Officer Implemented in 6 pilotRHUs in Cavite



Exhibit 14. Table of Philippine Department of Health information systems

Name of System Function Target Users Status

Integrated Drug TestOperation andManagementInformation System(IDTOMIS)

Maintain data on accreditation ofdrug testing centers, testingactivities, regulatory oversight,and drug test results

DOH - Bureau of HealthFacilities and Services,National ReferenceLaboratory, Centers forHealth Development DrugTest Centers,Rehabilitation Centers,Agency DataBeneficiaries Daily use.

National ElectronicInjury SurveillanceSystem (NEISS)

Captures injury-related data in anelectronic format from healthfacilities (e.g. hospitals, ruralhealth units, and barangay healthstations. Can submit dataelectronically to the HOMIS.

National ElectronicDisease SurveillanceSystem (NEDSS) /NationalEpidemiologicalSentinel SurveillanceSystem (NESSS)

Collects notifiable disease datafrom local and state stakeholdersThese case reports includelaboratory data, treatment data,and vaccination data.

DOH secretary, nationalprogram managers,media, other stakeholders(e.g. academe,researchers, LGUdecision makers)

National Health AtlasGeographicInformation System(NHAGIS)

Maps all public health facilities inthe Philippines, an initiallycollected baseline health data onwomen. Provides profile of facilityincluding personnel andequipment with road contours.

District Health Officer

Payroll System Manage payroll records for DOHpersonnel

Regional / ProvincialHealth Officer

Implemented in centraland regional offices, 9hospitals, and 4 DOHagencies

Rural Health UnitManagementInformation System(RHUMIS)

Manage electronic patient recordsand generate FHSIS reports inRHUs

Facility Chief / HealthOfficer

Implemented in threeRHUs (South Cotabato,Kalinga and Surigao delNorte). No activity since2005.

Sentrong SiglaMonitoring System

Certification and recognitionprogram that promotes standardsfor health facilities

Regional / ProvincialHealth Officer

Traditional AlternativeHealth Care (TAHC)

Tracks various modalities andtheir experts in traditional andalternative health care

Health SystemAdministrative Managers

Work and FinanceSystem

Monitors planned activities andwork and financialaccomplishments of DOH offices,services and regional offices.

National Planning andInformation Officer

6.1.2 The Community-Based Monitoring System (CBMS)

In addition to the DOH systems listed in Exhibit 14, in the early 1990s the Philippines NationalEconomic Development Authority developed a Community-Based Monitoring System (CBMS) tohelp monitor poverty and track progress towards achieving the Millennium Development Goals(MDGs). The CBMS is designed to provide disaggregated data for planning, program



formulation, policy impact, and poverty monitoring at the local level. The CBMS has beenadopted by the National Anti-Poverty Commission (NAPC) and the Department of Interior andLocal Government (DILG) as the local poverty monitoring system and a tool for localizing theMDGs.

The core CBMS indicators include several health indicators as follows:

Proportion of child deaths aged 0-5 years Proportion of women deaths due to pregnancy related causes Proportion of malnourished children aged 0-5

Data for these indicators originate in health units, including barangay health stations and RHUs.

By May 2007 the CBMS had been implemented in twenty (29) provinces, (15 of which wereprovince-wide), 347 municipalities, 24 cities, covering 9,116 barangays.35 The CBMS Networkand the Working Group on MDGs and Social Progress of the Philippine Development Forumboth envision that the entire Philippines will be covered by CBMS by 2010.

The following sections describe what we know about existing information systems related tohealth services delivery and how they may be related to the proposed electronic medical recordsystem for RHUs.

6.2 Hospital Operations and Management Information System (HOMIS)

The Hospital Operations Information Management Information System (HOMIS) is a MicrosoftWindows-based computerized hospital information system for government hospitals. It has beendeveloped by the DOH through the National Center for Health Facilities Development andInformation Management Service. HOMIS is designed to support improved hospitalmanagement for effective and quality health care. The development and implementation ofHOMIS is a defined information systems development strategy under Hospital System Reformsof the DOH.

HOMIS consists of three (3) modules as follows:

1. Patient Management2. Services Provision3. Administration

The Patient Management Module supports outpatient and emergency room consultations,admission, discharge, billing, payment (Cashier System), medical records, Philippine HealthInsurance Corporation (PHIC/PhilHealth) claims processing, medical social services and referralsystem requirements.

The Services Provision Module ensures the efficient provision of clinical services to the patientthroughout the hospital stay. This includes nursing care or ward, pharmacy, laboratory,radiology, dietary, central stock room and other ancillary services.

35Capones E. Institutionalizing the Community-Based Monitoring System (CBMS) in the Philippines. 6th

PEP Research Network General Meeting, Lima, Peru, 2007.



The Administration Module includes budgeting, obligations accounting, procurementmanagement, human resources management, materials management, fixed assetsmanagement, general ledger, accounts payable, and other financial and administrative systems.

HOMIS is designed to provide standard reporting data to the FHSIS. Exhibit 15 is a conceptualdiagram showing the flow of information regarding births from the HOMIS to the FHSIS.

By August 2006 HOMIS had been installed and implemented in forty-two (42) governmenthospitals. Most of these hospitals had implemented the Patient Management Module, but wereunable to implement the remaining two modules due to insufficient funds for the requiredcomputing infrastructure. Depending on the size of hospital, HOMIS requires an investment ofbetween four and eight million Pesos for a server, client computers, networking equipment, andsoftware licenses.36

Exhibit 15. Diagram showing the flow of information regarding births from the HOMIS to the FHSIS.37

6.3 Rural Health Unit Management Information System (RHUMIS)

The Rural Health Unit Management Information System (RHUMIS) is a computerized publichealth information system designed for the RHUs. The system is a tool to efficiently andeffectively monitor patient cases in the rural health units. The system was developed inMicrosoft Access by the Integrated Community Health Services Project (ICHSP) of the DOHand was designed to be used by health facility managers (Facility Chief or Health Officer). Thesystem can be linked to HOMIS and generates FHSIS reports.

36HOSPITAL INFORMATION MANAGEMENT SYSTEM (HOMIS), IMPLEMENTATION PROCESS, DOH

37Based on a diagram prepared by Teresita R. Cacdac of the Tarlac Provincial Health Office.



Development of the RHUMIS began in 2002 and was implemented in three RHUs (SouthCotabato, Kalinga and Surigao del Norte) by 2005.38 Scale-up was hampered due to lack ofnecessary computing hardware, a full-time administrator, and standard operating procedures.39

The DOH has not published new information concerning the status of the RHUMIS since 2005.

7 Proposed Partners and their Roles

The success of this project depends on the commitments and successful collaboration of thefollowing partners:

DOH Center for Health Development, Region 3, Central Luzon (CHD-3) DOH Information Management Service (IMS) DOH National Center for Disease Control and Prevention (NCDCP) DOH National Epidemiology Center (NEC) Health Unit Personnel/Municipal Health Officers (MHO) Local Government Units (LGUs) National Telehealth Center (NThC), University of the Philippines (UP) Qualcomm Wireless Reach RTI International (RTI) Smart Communications Inc. (SMART) Tarlac Provincial Health Office (PHO) Tarlac State University (TSU) USAID HealthGov Project

Exhibit 16 is a table of proposed project partners and their respective roles. The followingsections describe the proposed role and contribution of each project partner in further detail.Partners are listed in alphabetical order. This partnership is not exclusive, and additionalpartners may be identified during project implementation. In the table below, in-kindcontributions include staff time and technical expertise, donation of equipment and wirelessnetwork services, use of partner facilities for project activities, and direct funding of projectactivities, such as meetings, workshops, and training. The following sections describe theproposed role and contribution of each project partner in further detail.

Exhibit 16. Table proposed partners, possible roles, points of contact, and suggested type ofcontribution.Partner Type of

PartnerPossible Roles Points of

ContactContribution

DOHCenter for HealthDevelopment,Region 3, CentralLuzon (CHD-3)

Government Provide support and leadership forlocal stakeholders meeting.Provide guidance on projectdesign. Ensure compatibility withFHSIS standards and integrationwith FHSIS. Participate onTechnical Implementation Team.

Dr. RioMagpantay,Director, CHD-3

Ms. Luz Campos,FHSISCoordinatorCHD-3

In-kind

38Philippines National Economic Development Authority. Accessed at

http://www.neda.gov.ph/progs_prj/ICT/ProjectDetails.asp?ProjID=65 on 24 April 2009.39

Global Health Information Network. Accessed at http://www.tghin.org/node/158 on 24 April 2009.





ContactContribution

DOH InformationManagementService (IMS)

Government Provide guidance concerning therelationship and interoperability ofhealth information systems, suchas interoperability with HOMIS andother systems developed andsupported by IMS.

Ms. Crispinita A.Valdez, DirectorIII

In-kind

DOHNational Centerfor DiseaseControl andPrevention(NCDCP)

Government Provide guidance on projectdesign. Ensure compatibility withDOH requirements and standards.Participate on TechnicalImplementation Team.

Dr. Yolanda E.Oliveros -Director IV

In-kind

DOHNationalEpidemiologyCenter (NEC)

Government Provide guidance on projectdesign. Ensure compatibility withFHSIS standards and integrationwith FHSIS. Participate onTechnical Implementation Team.

Dr. EricTayag,,DirectorIV

Dr. Marlow O.Niñal, DivisionChief, PublicHealthSurveillance andInformaticsDivision

Dr. Vikki Carr delos Reyes,SurveillanceOfficer, NationalFHSISCoordinator,Public HealthSurveillance andInformaticsDivision

In-kind

Health UnitPersonnel/Municipal HealthOfficers (MHO)

Government Nurses, midwives and doctorsproviding care at the BarangayHealth Station (BHS)/RHU/CHUlevel will be the backbone of thissystem. They will participate indefining softwareenhancements/design to ensurethe system works for them. Theywill also assist in testing the systemand in reporting any issues to thesoftware development team.

TBD In-kind

LocalGovernmentUnits (LGUs)

Government Participation of chief executivesand other personnel in stakeholdermeetings, project launch activities;participation of Municipal HealthOfficers in project training activities,including transport to and from thetraining site.

Local ChiefExecutives

In-kind





ContactContribution

NationalTelehealthCenter (NThC),University of thePhilippines (UP)

University Collaboration on enhancements toCHITS, orientation of TSU and RTIteam on CHITS, design of trainingfor RHU/CHU personnel, andpackaging of CHITS as anaffordable service for localgovernment units.

Dr. AlvinMarcelo, Director

In-kind

QualcommWireless Reach

Private Sector Grant funding for projectimplementation by RTIInternational, including sub-grantfunding for software enhancement,testing, and technical support;liaison with SMART; overall projectoversight.

Linda Lee,Manager,GovernmentAffairs, WirelessReach

MantoshMalhotra,QualcommCountryManager,Philippines

Julie Welch,SeniorGovernmentAffairs Manager,Qualcomm

Grant fundingfor projectimplementationby RTIInternational

RTI International(RTI)

Non-profit non-governmentalorganization

Project strategy, planning, andimplementation; technicalassistance and oversight ofsoftware development, testing, andtraining programs; project statusreporting to Qualcomm andthrough Qualcomm to other projectstakeholders.

Eileen Reynolds,Project Manager

Michael McKay,Technical Lead

GordonCressman,Senior Director,Center forInformation,Communication,and Technology

NA

SmartCommunicationsInc. (SMART)

Private Sector Provide computer and connectivityhardware, services and technicalsupport for data transmissionbetween RHUs and centraldatabase and participate on theTechnical Implementation Team.

Darwin Flores,Senior Managerfor CommunityPartnerships,Public AffairsGroup

In-kind

Tarlac ProvincialHealth Office(PHO)

Government Lead project in cooperation withlocal government units; MunicipalHealth Officers; and theDepartment of Healthrepresentative office and Center forHealth Development office forRegion 3 (CHD-3); assist indeveloping software requirementsand testing software.

Dr. RicardoRamos,Provincial HealthOfficer

In-kind





ContactContribution

Tarlac StateUniversity (TSU)

University Software development, testing,deployment, and technical support;training of clinicians; use of TSUfacilities for software developmentand possibly project partner andstakeholder meetings, workshops,and training.

Dr. PriscillaViuya, UniversityPresident

In-kind

USAIDHealthGovProject

Bilateral donor Advise on project strategy andimplementation; liaison with theDepartment of Health; ensureproject activities are integrated withUSAID HealthGov objectives andactivities; advise concerningstakeholders and public healthsector finance; assist in planningand making logistical arrangementsfor some project activities;temporary use of office facilities inManila for visiting RTI personnel.

Maria Paz deSagun,AgreementOfficer’sTechnicalRepresentative(AOTR)

Harry Roovers,Chief of Party,

EasterDasmarinas,Deputy Chief ofParty

In-kind

7.1 DOH Center for Health Development, Region 3, Central Luzon (CHD-3)

The Center for Health Development (CHD) is responsible for DOH field operations in eachadministrative region. CHD regional offices are charge with providing efficient and effectivemedical services; implementing laws, regulations, policies, and programs; and coordinating withregional offices of the other government agencies as well as with LGUs. The CHD Region III(CHD-3) office in San Fernando City houses the Regional Epidemiological Surveillance Unit(RESU). This unit receives and processes routine FHSIS data reports from the Tarlac PHO. Atotal of seven (7) personnel from the CHD-3 office are assigned to the CHD representativeoffice in Tarlac City. A total of 17 personnel from the CHD-3 office are assigned to variousvertical health programs in Tarlac province.

The proposed role of the CHD-3 office includes the following activities:

Serving on the Stakeholders Advisory Board and Technical Implementation Team Providing guidance concerning the application of FHSIS technical standards and

guidelines and FHSIS data collection, validation, consolidation, and use at the regionallevel

As a member of the Technical Implementation Team, participating in softwaredevelopment and integration with the existing FHSIS

Reviewing and approving electronic reporting standards Helping to develop a scale up strategy and plan contingent on the success of the pilot

project



7.2 DOH Information Management Service (IMS)

The Information Management Service (IMS) within the DOH Central Office is responsible forensuring access to knowledge for evidence-based decision making. The IMS seeks toaccomplish this by optimizing the use of information technologies through dynamic, responsive,and integrated information systems. Specifically, the IMS does the following:

Formulates and implements plans, programs and standards for managementinformation technology development within the DOH

Develops and manages health and management information systems for theDOH

Develops and manages DOH information system infrastructure, includingcorporate databases and telecommunications services

Develops tools to utilize intellectual capital of DOH Ensures IT knowledge and skills transfer within the DOH Advises the Secretary of Health on matters pertaining to information

management.

Provides IT-related technical assistance to DOH officesThe IMS develops and supports several important related health information systemcomponents, including HOMIS.

The proposed role of IMS includes the following activities:

Serving on the Stakeholders Advisory Board Providing guidance concerning interoperability with HOMIS and other IMS developed

and supported information system components that may be related to the proposedsolution.

Providing guidance concerning DOH technology standards Contributing to the development of a scale up strategy and plan contingent on the

success of the pilot project

7.3 DOH National Center for Disease Control and Prevention (NCDCP)

The National Center for Disease Prevention and Control (NCDPC) was established as part ofthe DOH Central Office in 1999. The NDCPC is the national technical authority responsible fordisease prevention and control, including surveillance and response systems. NCDPC diseasecontrol programs include HIV/AIDS, Tuberculosis, and Malaria.

The USAID HealthGov works with the NCDPC to pilot of new approaches to service standardsand quality improvement, service delivery performance analysis. The NCDPC is a key user ofFHSIS data at the national level.

The proposed role of the NCDPC includes the following activities:

Serving on the Stakeholders Advisory Board Providing guidance concerning the needs of the NCDPC with respect to FHSIS reporting

and other data reporting needed from barangay health stations and RHUs Advising the project concerning the timeliness and quality of data reporting with respect

to NCDPC needs



Helping to develop a scale up strategy and plan contingent on the success of the pilotproject

7.4 DOH National Epidemiology Center

The DOH National Epidemiology Center (NEC) is responsible for developing national diseasesurveillance systems and other health information systems that collect, analyze, anddisseminate information on the public health status. The NEC also investigates diseaseoutbreaks and other threats to public health. The NEC maintains a network of public healthlaboratories in support of epidemiological and surveillance activities. The NEC Public HealthSurveillance and Informatics Division (PHSID) is responsible for coordinating with stakeholdersthroughout the public health system to establish and promote standards and guidelines for theFHSIS. The PHSID uses FHSIS reports from regional epidemiology surveillance units toproduce an FHSIS annual report.

The proposed role of the NEC includes the following activities:

Serving on the Stakeholders Advisory Board and Technical Implementation Team Providing technical standards and guidelines with respect to FHSIS data reporting

requirements As a member of the Technical Implementation Team, participating in software

development and integration with the existing FHSIS Reviewing and approving electronic reporting standards Helping to develop a scale up strategy and plan contingent on the success of the pilot

project

7.5 Health Unit Personnel/Municipal Health Officers (MHO)

Clinicians (nurses, midwives and doctors) providing care at the BHS/RHU/CHU level will be theprimary users of the EMR system. These include barangay health workers and midwives whovisit households in their barangays to follow up patients and provide health care services,midwives responsible for consolidating patient data for monthly FHSIS reporting, and physiciansserving as MHOs who are responsible for reviewing and approving these reports. Theseclinicians will participate in defining software enhancements/design to ensure the system worksfor them. They will also assist in testing the system and in reporting any issues to the softwaredevelopment team.

The proposed role of clinicians in includes the following activities:

Potentially visiting existing CHITS installations to see the system in use and to discussexperiences with current users

Participating in orientation and consultative workshops to understand and contribute tothe design of the system

Participating, as needed, in training, including computer literacy training Testing the software and providing feedback to the Technical Implementation Team

concerning problems, functions, and features Reviewing, testing, and providing feedback on user guides, manuals, and training

materials to the Technical Implementation team



Participating in the project launch ceremony and potentially other public relations eventsto make the public aware of the system and its potential benefits

7.6 Local Government Units

LGUs are responsible for managing public health care delivery through barangay health stationsand RHUs. As explained in section 2.1, City Health Officers and Municipal Health Officersreceive and review routine FHSIS reports from RHUs before submitting them to the PHO. Anyelectronic medical record system designed for RHUs must have the full political and fundingsupport of the relevant LGU. The LGU must understand and appreciate the value of the systemas well as all training and technical support costs and arrangements. LGUs in the samegeographical area may also pool support resources through an ILHZ. The proposed role ofLGUs that participate in this pilot project is as follows:

Participating in meetings to discuss project objectives and strategy Participating in meetings to evaluate technical alternatives and the sustainability of

operating costs Encouraging the participation and cooperation of city/municipal health officers RHUs, Providing supervisory support through city/municipal health officers Providing second-tier technical support for hardware and software installed in RHUs

7.7 National Telehealth Center, University of the Philippines

The Health Informatics Unit of the National Telehealth Center developed and continues todevelop CHITS. The Health Informatics Unit As described in Section 5.1, this project will buildon the CHITS effort by adding a data transmission module for FHSIS data reporting as part ofthe CHITS open source software project. The proposed role of the University of the Philippinesis as follows:

Serving on the Stakeholders Advisory Board and Technical Implementation Team Sharing information and providing guidance to TSU in becoming a CHITS reference site Providing TSU with access to CHITS training materials and other information related to

local capacity building Coordinating CHITS software enhancement with TSU Sharing lessons learned from previous CHITS implementations

7.8 Qualcomm Wireless Reach

As mentioned in Section 1.6, Qualcomm is a U.S.-based wireless telecommunications researchand development company founded in 1985. Qualcomm designs, manufactures and marketsdigital wireless telecommunications products and services. Examples include advanced 3Gmobile wireless products and integrated circuits that add Global Positioning System (GPS)capabilities to mobile phones. The Wireless Reach Initiative is part of Qualcomm CorporateSocial Responsibility (CSR). Qualcomm hopes that this project will help increase awareness ofthe full potential of their 3G technology, strengthen their relationship with SmartCommunications, present a positive image to the Government of the Philippines, and expandQualcomm’s share of the growing 3G market in Asia.



Qualcomm’s proposed role includes the following:

Coordinating and leading meetings of the Stakeholders Advisory Board Helping to mobilize and secure the commitments of project partners and to manage

communications with project partners Managing the overall relationship with Smart Communications Working closely with the RTI project team to monitor project strategy and implementation Coordinating public communications about the project with the Tarlac PHO and other

project partners Providing support to the Tarlac PHO to arrange a formal project launch event Helping to develop a scale up strategy and plan contingent on the success of the pilot

project

Qualcomm Wireless Reach participation will be lead by the Qualcomm Government AffairsManager. Qualcomm’s Philippines Country Manager and regional staff will participate inassisting with public communications and the overall relationship with the other partners.

Qualcomm Wireless Reach has provided grant funding to RTI to implement this project, and iscurrently the only partner who has made a funding commitment to the approximately one-yearpilot project.

7.9 RTI International

RTI International is a U.S-based not-for-profit research organization. RTI has a cooperativeagreement with USAID to implement the USAID HealthGov project, and has received a grantfrom Qualcomm Wireless Reach to implement this pilot project. The role of RTI is as follows:

Developing and communicating overall project strategy Developing and communicating the project work plan Managing and coordinating project activities and the project budget Selecting, hiring, and managing a fulltime local project coordinator Providing expert technical assistance in health informatics, including a thorough

understanding of international experience, trends, and stakeholders Providing expert assistance in technology transfer and change management strategies Contributing expert international knowledge and experience Providing expert technical assistance to TSU in open source software development and

data transmission Providing quality assurance of the software, software documentation, and training

materials Informing all partners of project risks and communicating realistic expectations Keeping all partners will informed of project status through routine reporting Serving on the Stakeholders Advisor Board and Technical Implementation Team

7.10 Smart Communications Inc.

Smart Communications will provide connectivity hardware, services, and technical support for3G data transmission between RHUs and the PHO. Smart BRO is Smart Communication’shigh-speed broadband Internet service. It uses the Smart Communications mobile phone



network to wirelessly connect computers to the Internet. Smart BRO is based on Qualcomm 3GWCDMA/UMTS technology. As of the end of June 2007 Smart BRO was available from 1,071sites spanning 165 cities and towns in the Philippines. Exhibit 13 is a map of SmartCommunications network coverage in central Luzon. In Tarlac Province Smart BRO is availablein Capas, Gerona, Moncada, Paniqui , and Tarlac City. Smart Communications has placed anetwork tower on the TSU campus and has collaborated with TSU to improve their educationprogram in telecommunications.

Smart Communications has a corporate social responsibility program. Launched in 2003, theSmart Communities Program is the umbrella for Smart’s community service and employeevolunteerism initiatives. In 2009 Smart Communications donated 16 computers and Internetconnectivity to Pasay City through the UP National Telehealth Center to support the CHITSeffort.

This project will ask Smart Communications to provide connectivity hardware, services, andtechnical support for data transmission between four (4) pilot RHUs and the PHO as anextension of Smart Communications support for expanding the use of CHITS.

The proposed role of Smart Communications includes the following:

Serving on the Stakeholders Advisory Board and Technical Implementation Team Conducting a site survey to verify and measure Smart network coverage at each of 36

RHUs within Tarlac Province Providing computer equipment and wireless broadband routers for four (4) pilot health

centers, at least one (1) wireless broadband router to the PHO, and at least two (2)wireless broadband routers to TSU for research and development

Providing data transmission services over the Smart Communications network for theduration of the one-year pilot project

Installing wireless broadband routers and providing related technical support for the one-year pilot project


It is anticipated that project partners, including Smart communications, will develop a plan forscaling up the system that will keep telecommunications costs for participating LGUs atsustainable levels.

7.11 The Tarlac Provincial Health Office (PHO)

The Tarlac PHO is responsible for supervising the provincial and district hospitals in theProvince, and for collecting, reviewing, and encoding all routine FHSIS data reports receivedfrom RHUs through municipal health officers. The PHO is the focal point for public health data inthe Province.

The proposed role of the PHO includes the following activities:

Serving on the Stakeholders Advisory Board and the Technical Implementation Team Leading the effort to coordinate and arrange a public project launch event Helping to engage the support of Local Chief Executives (LCEs) in the province.



Encouraging the participation and cooperation of municipal health officers. Providing standards and supervisory support for municipal health officers. Managing relationships with the data management unit of the DOH Center for Health

Development (CHD) representative office Managing the relationship with the Region III Regional Epidemiology Surveillance Unit

with respect to FHSIS reporting requirements Helping to gather baseline assessment and M&E data for RHUs and to select four (4)

pilot RHUs total in two (2) LGUs for the pilot project Helping to gather system requirements and develop project technical strategy Helping to liaison with the two (2) LGUs selected for the pilot project Helping to design and implement a communication program designed to inform all LGUs

in Tarlac Province about the pilot project, and its potential for scale up, and to solicit andanalyze input from LGUs into the design of the project

Providing second- or third-tier technical support to RHUs in the deployment and use ofthe electronic medical record system and the electronic data reporting module


It is expected that the PHO would coordinate all of these activities with other USAID HealthGovactivities through the USAID HealthGov Provincial Coordinator.

7.12 Tarlac State University (TSU)

TSU in Tarlac City is a chartered state university with 100 years of educational service to thepeople of Tarlac and Central Luzon Region. TSU has an enrollment of 11,000 and offersbachelors degrees in some 21 disciplines, including computer science; masters degrees in sixdisciplines, including information technology; and doctorates in three. In addition to the maincampus in Tarlac City, the TSU Villa Lucinda Campus is about 3 km away, and the San IsidroCampus, which houses the College of Technology, is about 1 km away.

The College of Computer Studies includes a Cisco Networking Academy program and programsin hardware and software engineering and information system management. Facilities includeseveral computer labs. Bachelors and post baccalaureate degree candidates of the College arerequired to complete a thesis project. These may include developing a proof-of-concept for aninnovative device or system. Students are required to identify a “customer” for the system andare given guidance in investigating, developing, and testing the concept and documenting theresults in their thesis. Previous thesis projects have included at least one use of mobile phonenetworks to transmit data.

TSU will become the local technical assistance provider for this one-year pilot project. RTI willconclude a subgrant agreement with TSU for the following activities:

Serving on the Stakeholders Advisory Board and Technical Implementation Team Helping to gather baseline assessment and M&E data for RHUs and to select four (4)

pilot RHUs total in two (2) LGUs for the pilot project Helping to ensure the selected LGUs and RHUs meet the basic requirements for CHITS

implementation Helping gather system requirements and develop project technical strategy



Becoming a CHITS reference center for Tarlac Province, participating in CHITS softwaredevelopment, training, and technical support to LGUs

Developing a CHITS electronic reporting module to transmit routine FHSIS data reportselectronically from each pilot RHU to the Tarlac PHO over the Smart Communicationsmobile phone network

Developing server software for the PHO to receive and process routine FHSIS datareports transmitted by the CHITS electronic reporting module

Conducting unit tests, load tests, usability tests, and other standard software tests toensure software quality and usability

Serving as local liaison with Smart Communications for project implementation Working with the PHO and Smart Communications to install the necessary hardware

and software in four (4) pilot RHUs Providing computer literacy and skills training for clinicians in four (4) pilot RHUs Providing computer literacy training and CHITS training for clinicians in four (4) pilot

RHUs Helping to support and monitor testing in four (4) pilot RHUs over a minimum three (3)

month pilot testing period Helping to collect M&E data and analyze pilot test results Contributing to the final pilot test project report Helping to develop a scale up strategy and plan contingent on the success of the pilot

project

This one-year pilot project will also seek to develop a sustainable program that will enable TSUto continue serving as a CHITS reference center to support the scale up of the system withinTarlac Province. Developing TSU in this role as a local technical assistance provider is essentialto successfully sustaining and scaling up the results of this one-year pilot project.

TSU participation will be coordinated through the TSU Vice President of Research, Extension,and Development.

It is anticipated that TSU will provide some in-kind contributions to this project through some useof existing TSU facilities and student labor in connection with student internships and thesisprojects.

7.13 USAID HealthGov

Close collaboration and coordination with the USAID HealthGov project is essential. ThisQualcomm Wireless Reach Philippines Partnership project was designed to further USAIDHealthGov project objectives and to support other USAID health projects by focusing on the rootcause of FHSIS data quality problems. As explained in Section 4, this project is consistent withthe USAID HealthGov Year 2 Work Plan for Tarlac Province, and will be an integral part ofUSAID HealthGov technical assistance in the Province. It is anticipated that USAID will play aprominent role in the Partnership and would participate on the Stakeholders Advisory Board.

The proposed role of the USAID HealthGov project includes the following activities:

Serving on the Stakeholders Advisory Board Providing logistical and technical assistance during project start-up to ensure integration

with USAID HealthGov technical assistance



Playing a leading role in liaison with the DOH to ensure project alignment with DOHstrategy and programs and to help gain DOH endorsement

Playing a leading role in LGU engagement strategy and activities Helping to develop a scale up strategy and plan contingent on the success of the pilot

project

RTI will work with USAID/Philippines to formulate this project according to the USAID GlobalDevelopment Alliance (GDA) framework. It is anticipated that the contributions of other Alliancepartners, including Qualcomm Wireless Reach, would meet or exceed the resource leveragingrequirements of a USAID GDA.

Subject to the approval of the USAID HealthGov Agreement Officers Technical Representative(AOTR), it is expected that overall strategic coordination of USAID HealthGov activities will bethrough the Project Management Group lead by the Chief of Party. Day-to-day coordinationactivities are expected to be coordinated through the USAID HealthGov Provincial Coordinatorfor Tarlac Province.

In addition to the USAID HealthGov project, USAID has several other important projects in thehealth care sector. These projects are also important stakeholders and are listed in the followingsection.

8 Engaging Other Stakeholders

In addition to the project partners described in the previous section, there are other government,private sector, and international donor stake holders in health information in the Philippines, andothers may emerge during the course of this project. For example, in addition to the NEC manyother departments and attached agencies of the DOH that have a stake in the national healthinformation system. As the principal health agency in the Philippines the DOH is responsible forensuring access to basic public health services to all Filipinos through the provision of qualityhealth care and regulation of providers of health goods and services. It is both a stakeholder inthe health sector and a policy and regulatory body for health. The DOH is a technical resource,a catalyst for health policy and a political sponsor and advocate for health issues in behalf of thehealth sector.

The DOH is a large and complex organization consisting of the following three major divisions:

Central Office Center for Health Development Attached agencies

The Central Office consists of the following bureaus and centers:

Bureau of Food and Drugs Bureau of Health Devices and Technology Bureau of Health Facilities and Services Bureau of International Health Cooperation Bureau of Local Health Development Bureau of Quarantine and International Health Surveillance



Finance Service Health Emergency Management Staff Health Human Resource Development Bureau Health Policy Development and Planning Bureau Information Management Service National Center for Health Facilities Development National Center for Disease Prevention and Control National Center for Health Promotion National Epidemiology Center Procurement and Logistics Service Research Institute for Tropical Medicine

The Information Management Service, National Center for Disease Prevention and Control,National Epidemiology Center, and Center for Health Development in Region III (CHD-3) areparticularly relevant to this project. These have been described in more detail previous sectionsof this report.

Agencies attached to the DOH include the following:

Dangerous Drugs Board (DDB) National Nutrition Council (NNC) Philippine Health Insurance Corporation (PHIC or PhilHealth) Philippine National AIDS Council (PNAC) Philippine Institute of Traditional & Alternative Health Care (PITAHC)

Of these, PhilHealth and the PNAC are perhaps most relevant to this project.

In 2007 the DOH sponsored the formation of the Philippine Health Information Network (PHIN),an organization of stakeholders with a critical stake in health information. Also in 2007 PHINcompleted a national review and assessment of the Philippine health information system. Thisproject should remain acutely aware of PHIN policies and activities through the DOH, the DILG,and other PHIN member organizations.

Exhibit 17 is a table listing these and other stakeholders who will be considered in developingproject strategy and may be included in the project communications and promotion plan.



Exhibit 17. Table of national and international project stakeholders.

Stakeholder Domain Description

Bureau of InternationalHealth Cooperation(BIHC)

National The Bureau of International Health Cooperation (BIHC) was establishedas part of the DOH Central Office to coordinate the implementation of thePhilippines Sector Development Approach in Health (SDAH) incooperation with international partners, DOH offices, and other keystakeholders. One of the objectives of the Bureau is to mobilize andcoordinate the contributions of development partners.

The USAID HealthGov project works with the BIHC to coordinate supportfor the implementation of Health Sector Reform and FOURmula ONE forHealth.

Remedios V.S. Paulino, DirectorFlorente E. Trinidad, Head, International Relations Division

Commission onInformation andCommunicationsTechnology (CICT)

National The Commission on Information and Communications Technology (CICT)is the primary policy, planning, coordinating, implementing, regulating,and administrative entity of the executive branch of Government thatpromotes, develops, and regulates integrated and strategic ICT systemsand reliable and cost-efficient communication facilities and services. TheCICT seeks to develop the Philippines as a world-class ICT servicesprovider, provide government services to stakeholders online, provideaffordable Internet access to all segments of the population, develop anICT enabled workforce, and create an enabling legal and regulatoryenvironment.

Ray Anthony Roxas-Chua III, Secretary, Chairman

Department of theInterior and LocalGovernment (DILG)

National The Department of Local Government and Community Development(DLGCD) was established by Executive decree in 1972. In 1982 theDLGCD was renamed Ministry of Local Government (MLG), and in 1987it was further reorganized and renamed Department of Local Government(DLG). The DILG was established to empower LGUs to deliver effectiveand efficient public service, The DILG provides general supervision ofLGUs, advises the government on local government legislation, andestablishes policies, plans, and programs to strengthen theadministrative, technical, and fiscal responsibilities of local governmentoffices and personnel. DILG supervision and assistance is providedthrough regional offices.

Ronaldo V. Puno, Secretary

The USAID HealthGov project coordinates closely with the DILG on awide range of activities designed to strengthen the capacity of localgovernments to manage public health services efficiently and effectively.





Inter-AgencyCommittee on HealthStatistics

National Formed under the leadership of the NSCB, the Inter-Agency Committeeon Health Statistics was formed under the leadership of the NSCB to 1)formulate measures that will improve the system of data collection andreporting of national and local health statistics; 2) recommendimprovements in the methodology of compilation of the PNHA or any ofits components and formulate measures to ensure that the datarequirements of the PNHA are being generated by all concernedagencies; 3) Identify and recommend statistical policies to the NSCBExecutive Board for the generation of data support on health issues; 4)Identify and develop key health indicators and standard healthparameters and recommend measures for the institutionalization of thegeneration and use of these indicators; 5) Monitor the over-alldevelopment of health statistics in the country.

Dr. Mario C. Villaverde, Undersecretary, Sectoral ManagementCoordination Team and PSDT for Service Delivery, Department of Health(DOH)

LGU leagues (LPP,LMP, LCP)

National Local government leagues in the Philippines include the following:

League of Provinces of the Philippines (LPP) League of Municipalities of the Philippines (LMP) League of Cities of the Philippines (LCP)

These three leagues provide a powerful forum for exchanging ideas andsharing information. The USAID HealthGov project coordinates activitieswith all three organizations.

National StatisticalOffice (NSO)

National The National Statistics Office (NSO) is the major statistical agencyresponsible in collecting, compiling, classifying, producing, publishing,and disseminating general-purpose statistics as provided for inCommonwealth Act (CA) No. 591.NSO has also the responsibility of carrying out and administering theprovisions of the Civil Registry Law as provided for in Act No. 3753 datedFebruary 1931.

Carmelita N. Ericta, Administrator, Civil Registrar General

Open Source HealthCare Alliance (OSHCA)

International The Open Source Health Care Alliance (OSHCA) is an international non-profit organization. It provides the collaborative platform and forum topromote and facilitate Free/Open Source Software in Health Care.OSHCA membership is a community of people, civil societies andprofessional bodies in health care and informatics industries thatpromotes the Free/Open Source Software Concepts in Health Care.OSHCA helps policy makers, commercial enterprises, and users takeadvantage of the benefits of Free/Open Source Software.

Philippine HealthInformation Network(PHIN)

National The Philippine Health Information Network (PHIN) is an interagency bodycomposed of agencies that have critical stakes in health information.PHIN was established in 2007 as an initiative of the DOH InformationManagement Service (IMS) to engage stakeholders in a national effort toharmonize and rationalize the health information system. PHIN was





established to play a critical role in defining policies on health information,developing a comprehensive health information strategic plan, andidentifying data source for specific public health indicators.The DOH sought to rationalize and restructure existing technical workinggroups and inter-agency committees as part of the PHIN. The DOHsought the participation of the Department of Interior and LocalGovernment (DILG) to ensure that LGU concerns were addressed.

PHIN members include the following government, education,professional, and donor organizations:

Department of Health (DOH) Department of the Interior and Local Government (DILG) National Statistical Office (NSO) National Statistical Coordination Board (NSCB) Philippine Council for Health Research and Development

(PCHRD) Population Commission (POPCOM) National Nutrition Council Food and Nutrition Research Institute (FNRI) University of the Philippines College of Medicine (UPCM) Other academic organizations Medical societies World Health Organization (WHO) Die Deutsche Gesellschaft für Technische Zusammenarbeit

(GTZ) Japan International Cooperation Agency (JICA)

In 2007 PHIN conducted a review and assessment of the Philippinehealth information system using the HMN assessment framework.

Philippine HealthInsurance Corporation(PHIC or PhilHealth)

National The Philippine Health Insurance Corporation (PHIC or PhilHealth) is aDOH-attached agency. PhilHealth is government corporation designed toensure sustainable, affordable and progressive social health insurancewhich endeavors to influence the delivery of accessible quality healthcare for all Filipinos. As a financial intermediary, PhilHealth aims overtime to develop a sustainable national health insurance program thatleads towards universal coverage, ensures better benefits for itsmembers at affordable premiums, establishes close coordination with itsclients through a strong partnership with all stakeholders, and provideseffective internal information and management systems to influence thedelivery of quality health care services.

PhilHealth is governed by a board chaired by the Secretary of Health.

Philippine NationalAIDS Council (PNAC)

National The Philippine National AIDS Council (PNAC) is a DOH-attached agencyand is the central advisory, planning and policy-making body for thecomprehensive and integrated HIV/AIDS prevention and control programin the Philippines. PNAC was created through Executive Order 39 signedby the President Fidel V. Ramos on December 3, 1992. PNAC serves asa venue for intensive policy discussion between government and NGOs.





Philippine NationalStatistical CoordinationBoard (NSCB)

National The National Statistical Coordination Board (NSCB) was created underExecutive Order No. 121 issued on January 30, 1987 as the policy-making and coordinating agency on statistical matters in the Philippines.The objective of the NSCB is to develop an orderly Philippine statisticalsystem capable of providing timely, accurate, relevant, and useful datafor the government and the public for planning and decision-making. TheNSCB is the highest policy making and coordinating body on statisticalmatters has put in place coordinating mechanisms to ensure generationof quality statistics for planning and policy making.

Estrella V. Domingo, Assistant Secretary General

Population Commission(POPCOM)

National The Population Commission (POPCOM) is a DOH-attached agencyestablished through Executive Order No. 233 in 1970. POPCOM wasmandated to serve as the central coordinating and policy making body ofthe government in the field of population. On October 10, 2006, PresidentGloria Macapagal-Arroyo issued guidelines and directive for the DOH,POPCOM, and local government units to take full charge of theimplementation of the Responsible Parenthood and Family PlanningProgram.

POPCOM is governed by a Board of Commissioners and managed byExecutive Director Mr. Tomas M. Osias.

Philippine MedicalInformatics Society(PMIS)

National The Philippine Medical Informatics Society (PMIS) was incorporated in1996 with the mission of promoting the use of information technology inmedicine. Since then, it has organized and participated in variousactivities in medical informatics. Among these were seminars byinternational medical informatics experts, seminars on use of onlinebibliographic databases, handheld devices, electronic health records, andsecurity of electronic health information.

The PMIS is a proponent of open source software development forhealth. The PMIS is a strong partner in the Standards for HealthInformation in the Philippines project as well as the BuddyWorksTelehealth Project and the upcoming Philippine National HealthInformation Infrastructure. The Society encourages the deployment ofhealth information systems in support of national development andpoverty alleviation through the full implementation of the PrimaryHealthcare Approach. Among the beneficiaries of its technical seminarsare community health workers, government midwives, and privatepractitioners.

PMIS is the official organization representing the Philippines at the AsiaPacific Association for Medical Informatics (APAMI) and subsequently,the International Medical Informatics Association (IMIA).

USAID CooperatingAgencies

National In addition to HealthGov, USAID Philippines has several other importantprograms designed to help improve public health in the Philippines.These include the following:

Sustained Health Improvements through Empowerment andLocal Development (SHIELD)





Linking Initiatives and Networking to Control Tuberculosis (TBLINC)

The Maguindanao Tuberculosis Control Project (MTCP) Maximizing Access to Child Health (MATCH) Program Health Promotion and Communications (HealthPro) Private Sector Mobilization for Family Health (PRISM) A2Z: The USAID Micronutrient and Child Blindness Project Health Policy Development Program (HPDP)

The projects are being implemented by several Cooperating Agencies(CA) directed by USAID. Many of these projects have activities in TarlacProvince that may be affected by or may affect this pilot project.

9 Project Resources

It is important for this pilot project to set appropriate expectations and achieve success for allpartners with the limited available resources. Qualcomm Wireless Reach has awarded a grantto RTI to implement this pilot project over a period of approximately 12 months. In addition toRTI’s role as the project implementer, as described in Section 7.9, this grant includes a sub-grant to TSU. These resources are designed to achieve project results in four (4) pilot RHUs intwo (2) LGUs and to lay a foundation for scaling up the system. The system will not have asignificant positive impact on the timeliness or quality of FHSIS reporting to the PHO until thesystem has been deployed to most of the RHUs (currently 36) in Tarlac Province. Therefore it isimportant for this pilot project to demonstrate feasibility, measure results, develop a practicaltechnical and organization system for scale-up, and build a partnership that can continue toprovide support for scaling up the system after the end of Qualcomm Wireless Reach funding.

As described in Section 7 this project also depends heavily on in-kind contributions of labor,materials from other partners. It may be necessary to reallocate grant resources and reduceproject scope if one or more project partners do not provide the expected in-kind contributions,or do not provide them in time to keep the project on schedule. It will be important for all projectpartners to have a clear mutual understanding of project scope, expected results, thecommitments of each partner, the project work plan, and current project status. Equipmentcontributions from partners could free some grant resources for additional project activities.

10 Sustaining the Solution

Sustainability issues can be grouped into the following major categories:

Adoption of the medical record system by clinicians Official acceptance of the electronic reporting system The operating cost of the computing hardware, software, and networking services The effectiveness and affordability of the technical support system



Each of these issues is addressed in more detail in the following sections

10.1 Adoption

Willing adoption of the medical record system by clinicians is a fundamental requirement forlong-term sustainability. To be accepted, the system should do the following:

Accurately reflect and respond to the flow of clinical protocols Meet the daily information needs of clinicians Save clinicians time by automating reporting and other routine tasks Be responsive and reliable Include a well-structured and sustainable training and support system

In general the system should provide a positive return on the time clinicians spend entering andmaintaining the data and maintain that performance consistently over time. To achieve this, thesystem should be developed in partnership with clinicians and under the supervision ofphysicians to reflect both the reality of clinical operations and accepted standards of clinicalpractice. This fosters local ownership and minimizes the gap between technical conception andclinical reality. A well-structured training and support system positively engages clinicians notinvolved in system development and helps to mitigate the impact of staff turnover.

The project has taken the first step in addressing this issue by proposing to build on CHITS, anexisting electronic medical record system designed with local clinicians to meet Philippinestandards of care. The CHITS program also includes a tested user training and certificationsystem. Building on CHITS minimizes the gap between technical conception and local reality,reducing project risk while providing a foundation for further enhancement. CHITS will need tobe enhanced to meet the needs of this pilot project in collaboration with clinicians, the PHO,TSU, the National Telehealth Center, and the DOH. This effort should help to create acollaborative free and open source software development community in the Philippines that cansustain the electronic medical record system software.

The selection of Smart Communications as a telecommunications partner provides access to awireless network with national coverage and 3G data transmission capability. SmartCommunications is the leader in 3G wireless broadband coverage and services in thePhilippines. The Smart Communications network should provide the speed and reliabilitynecessary for data transmission and the potential for national scale up.

10.2 Official Acceptance

Official DOH acceptance of electronic reporting is necessary to support electronic reporting formthe PHO to the RESU, and from the RESU to the NEC central office. While it is possible totransmit paper facsimile reports in electronic form, more efficient electronic formats could enabledata to flow directly into databases, avoiding data re-entry errors. While DOH and PHIN policysupports this principle, it will be important to work with the DOH to develop acceptable andofficially approved electronic formats.



The project will address this by working closely with DOH stakeholders, demonstrating thefeasibility of electronic reporting, and demonstrating the advantages of alternative electronicformats.

10.3 Operating Costs

Operating costs of the system will include the following costs:

Consumable supplies Software licensing costs Technical support and maintenance for computer and networking equipment Telecommunication services necessary to transmit data over the Smart Communications

wireless network

Most of these costs will need to be incorporated into LGU budgets. Sustainability and scalabilitywill depend on minimizing these costs and an open dialogue with LGUs and other projectpartners concerning affordability. This dialogue should also address the challenge of plannedequipment replacement, an issue frequently ignored. Participation of the USAID HealthGovproject will be essential to understanding public health care financing and identifyingstakeholders, resources, and mechanisms for funding local operating costs. The USAIDHealthGov project can help to integrate these costs into the Province-wide Investment Plan forHealth (PIPH).

The project strategy described in this document helps to address this issue by using free andopen source software. It also describes a technical solution that can be effective with minimalinfrastructure and scaled up as local carrying capacity increases. The project will need to payclose attention to balancing the cost, reliability, and local sources of support for the necessarycomputer equipment.

The continuing cost of the Smart Communication services necessary for electronic reporting is asignificant concern. Smart Communications has already contributed computers, networkconnection equipment, and network services to the CHITS project and will also be asked toprovide network connection equipment and network services to this pilot project. The project willwork with Smart Communications and other project partners, including LGUs, to develop asustainable solution for providing network connection equipment and connectivity to additionalLGUs as part of the scale-up plan.

10.4 Technical Support

The project will also need to develop a simple but well-structured technical support systemcapable of responding to the needs of remote RHUs. The selection of TSU as a local technicalassistance provider is designed to provide LGUs with a cost-effective source of continuedtechnical support for the software, and potentially for the hardware. To be responsive to needsin RHUs, the system is likely to be arranged in tiers, with specially trained clinicians providingthe first tier of support by diagnosing and resolving the most common problems on site. Thesecond tier of support may be trained City/Municipal Health Officers, while the third and final tiermay be a contracted private sector support provider or university-based technical supportprogram. This technical support system will be developed in collaboration with localstakeholders at these various levels in Tarlac Province.



11 Scaling Up the Solution

As described in Section 4, the electronic medical record system developed and pilot tested bythis project should contribute to meeting the health information needs of decision makers. Thepilot project should benefit clinicians in the four (4) selected pilot RHUs. The electronic medicalrecords system will have a significant impact on the timeliness and quality of FHSIS datareporting to the PHO only if the system can be implemented and sustained in most RHUs inTarlac Province. Similarly, results cannot be achieved at regional and national levels unless thesystem can be implemented and sustained in most RHUs in the Philippines. The technicalapproach described in this document should be scalable technically, but deployment of thesystem in RHUs will depend on awareness and demand from LGUs, affordable costs, a welldeveloped support system, and the official endorsement and support of the DOH.

This one-year pilot project will seek to draft a framework that will help LGUs to replicate andsustain the system. This draft framework will include the following:

A support and certification system to help LGUs to understand and realize the potentialof the system to improve health care services, and to encourage them to meet theinfrastructure, human capacity, and financial requirements of the system

A well-developed training and certification system for RHU clinicians to help them tounderstand the benefits of the system in their work, enable them to use the systemeffectively, and to reward them for this achievement

A local technical assistance system based around a system of regional referencecenters, using the example of TSU, that collaborate to maintain and enhance the opensource software and provide continuing support to LGUs

Engaging and collaborating with the DOH to develop electronic reporting standards forFHSIS data and gain DOH endorsement and PHIN recognition of the system as part ofthe Unified Health Information Management System

Contingent on the results of this pilot project, project partners will discuss the potential forscaling up this system in Tarlac Province, and providing the system to other LGUs around thePhilippines. The draft framework for replicating the system will provide an important basis forthis discussion. USAID HealthGov is anticipated to play a leading role in developing a scale-upstrategy consistent with the USAID HealthGov work plan. Risks and MitigationHeeks40 and other researchers have noted that most health information system projects fail.Heeks points to significant gaps between technical conception and reality as the primary causeof failure. These gaps fall into three major categories:

Gaps that can occur between the formal, rational way that an information system isconceived and the behavioral realities of health care organizations.

Gaps that can occur when private sector solutions are applied in a public sector context Gaps that can occur when an application from one country is applied to another country

without being sufficiently adapted to the local context.

40Heeks, R., D Mundy, A Salazar (1999) 'Why Health Care Information Systems Succeed or Fail', IDPM

Information Systems for Public Sector Management Working Paper no.9 , 0. Accessed athttp://www.sed.manchester.ac.uk/idpm/research/publications/wp/igovernment/ on 6 May 2009.



Heeks suggests that risks to health information system projects can be reduced significantly byminimizing gaps across the following seven dimensions:

Information Technology Processes Objectives and values Staffing and skills Management and structures Other resources: money and time

Information and communication technology (ICT) projects in international development havealso had a dismal track record of success beyond the pilot phase. RTI has developed a simpleframework for success in ICT-for-development projects based on many years of experience.This framework, called “the ICT three-legged stool,” requires a project to successfully addressthe following three major components:

Access: Access encompasses language, knowledge, skills, language, andtelecommunications

Useful content and services: Information and services that are useful to users Communication and promotion: Communicating and promoting the availability, value,

and effective use of the system

The strategy for the Qualcomm Wireless Reach Philippines Partnership project addresses boththe Heeks framework and the ICT three-legged stool by doing the following:

Building on CHITS, an existing system designed in the local context with theparticipation of health center clinicians

Engaging a local university as a technical assistance provider Developing a public private partnership that engages key local and national stakeholders Coordinating the activity with the broader package of USAID HealthGov technical

assistance activities, which are based on a thorough understanding of healthgovernance in the Philippines

12 Management and Staffing

This project will be a USAID HealthGov activity in partnership with Qualcomm, Inc. and withsupport from RTI Headquarters staff and a consultant. The HealthGov team, led by Mr. HarryRoovers, COP, will lead reporting and ultimately management of this activity toUSAID/Philippines.

RTI Project Manager Ms. Eileen Reynolds (approximately 59 days over the first 12 months ofthe project) will lead reporting to Qualcomm, in liaison with Mr. Roovers and Ms. EasterDasmarinas, USAID HealthGov Deputy Chief of Party. Ms. Reynolds has more than ten yearsof experience managing projects and providing technical assistance in M&E and ICTapplications and assessments. Ms. Reynolds managed RTI activities for the Zambia ElectronicPerinatal System (ZEPRS) project and is currently managing RTI activities for the QualcommWireless Reach Partnership – Kenya.



RTI consultant Mike McKay will serve as lead Technical Advisor for the project with 153 days oflabor over the first twelve months of the project. He will work closely with the PHO, MunicipalHealth Offices and RHU staff as well as DOH, TSU, and the University of the PhilippinesMedical Informatics Unit to design the system. Mr. McKay was the Country Director for theground-breaking Baobab Health Partnership in Lilongwe, Malawi, from 2006 through 2008, andis a consultant to the WHO in electronic health data standards. Prior to his position with theBaobab Health Partnership Mr. McKay worked for five years as a software engineer andtechnologist in the private sector.

Mr. Gordon Cressman, Senior Director of RTI’s Center for Information, Communication, andTechnology, will serve as Senior Technical Advisor, providing overall management andtechnical guidance and oversight for the project.

RTI will recruit, hire, and manage a fulltime Local Project Coordinator to coordinate projectactivities with the USAID HealthGov project in Tarlac Province, to carry out, manage, andoversee project activities locally to keep the project on schedule, to keep other members of theRTI project team well informed, and to help ensure that short term technical assistance iscarried out as efficiently as possible.

In addition, a Local Governance and Health Advisor, Conrad Castillo, will serve as part timeconsultant to assist with the project in Tarlac. Mr. Castillo recently served as ProvincialCoordinator for Tarlac with the HealthGov project.

Exhibit 19 is a table of individual project team members involved in this activity and their roles.

Exhibit 18 Table of individual project team members and their roles.

Project Team Member Role

Harry Roovers, HealthGov COP Oversight of the activity as a part of HealthGov Assist in scale up strategy Lead liaison with USAID/Philippines regarding this activity

Easter Dasmarinas, Deputy COP,HealthGov

Oversight of the activity as a part of HealthGov Assist in scale up strategy

Alex Herrin, LGU Governance Team Leader,HealthGov

Oversight of the activity as a part of HealthGov Liaison and coordination with DOH, Local and Provincial

Governments Assist in scale up strategy

Provincial Coordinator, Tarlac, HealthGov Ensure integration of activity into HealthGov technical assistanceplan for Tarlac

Meet regularly with local project coordinator and local partners toprovide oversight and support

Assist in scale up strategy Assist with local government relations

Regional Coordinator, Luzon, HealthGov Meet regularly with the HealthGov Provincial Coordinator toprovide oversight and support

Assist in scale up strategy Assist with local government relations





Eileen Reynolds (59 days over 12 months),RTI Home Office Technical Manager

Provide regular updates on project progress to Qualcomm andUSAID

Lead communications with the HealthGov team Lead communications with the PHO, TSU, Smart

Communications and other potential partners Lead the development of the project work plan and oversee

project implementation Lead the development of the project M&E plan and oversee

implementation of the M&E plan Supervise and provide support to full time local project

coordinator based in TarlacMike McKay (RTI consultant, 153 days over12 months) Lead Technical Advisor

Lead in crafting technical strategy for the system in partnershipwith stakeholders

Lead in developing software requirements Select, configure, and manage the use of team development

tools for team coordination, including task management, bugtracking, and software version control

Lead in working with TSU to test software, including leading thedevelopment of software unit, regression, and integration testing.

Lead strategy to ensure local software support in cooperationwith Tarlac State University (build capacity of TSU to support thesystem developed), the PHO and other local partners and RTIteam members.

Lead strategy to build a sustainable IT support system forRHUs/MHOs/PHO for this system, lead in implementing thisstrategy with local partners

Work with RTI team and local partners to develop a trainingstrategy and implement a training program for RHU personneland others who will use this system.

Provide software development expertise and capacity building toTSU as needed within the parameters of the project and budgetto enable them to support the system developed.

Local Project Coordinator (fulltime) based inTarlac

Work closely with the Project Manager to ensure that the projectstrategy, budget, and timeline reflect local realities

Work closely with the USAID HealthGov Provincial Coordinatorfor Tarlac Province to ensure the integration of activities with theUSAID HealthGov project

Keep the RTI Project Manager and other members of the RTIproject team well informed through regular routine reporting andfrequent pro-active communication

Manage local project activities according to the project timeline Coordinate with and keeping all project partners well informed Help gather and analyze software requirements, and coordinate

software testing Help create training materials and to coordinate and deliver

training; Assist with travel and meeting arrangements and providing

logistical support for RTI project team members on short-termtechnical assistance assignments for this project in TarlacProvince

Arrange workshops and manage workshop logistics Gather information from RHUs and other sites as needed Manage finances and tracking invoices for local procurement Assist with the installation of computer hardware in RHUs, PHO

and MHO Lead data collection for project monitoring and evaluation and

draft quarterly project reports





Conrad Castillo, Local Governance andHealth Advisor

Providing guidance to the project team on local governance andhealth in Tarlac

Discussing with LGUs and providing an evaluation of what LGUsin Tarlac can afford in terms of sustaining the electronic medicalrecords system

Working with the team and stakeholders to design a package ofservices around the electronic medical records system so that itcould be easily adopted and/or adapted by LGUs who areinterested. This would include the equipment, training andmaintenance required.

Keeping the RTI Project Manager and other members of the RTIproject team well informed on his activities and on developmentsthrough regular routine reporting and frequent pro-activecommunication

Assisting in the consultative processes to gain LGU andbarangay level inputs into the system. This could includeassistance in the design and delivery of consultative workshopsand other type activities.

Helping to gather and analyze software requirements Helping to identify and help to establish communications with

pilot LGUs/RHUsGordon Cressman (11 days over 12months), Director of the Center forInformation, Communication andTechnology in RTI’s InternationalDevelopment Group

Serve as senior technical advisor providing oversight andguidance to the project team on system design and projectimplementation.

Exhibit 20 is a proposed organizational chart, showing the members of the partnership, themembers of the RTI technical assistance team, and direct reporting relationships. It should benoted that this chart lists only the chief executive for each partner. Chief executives maydesignate on or more members of their staff as contacts and participants in partnershipactivities. It should also be noted that additional partners may be added during the course of theproject to ensure inclusion of stakeholders.



12.1 Project Coordination

The RTI Project Manager and RTI Technical Lead will hold weekly conference calls with thePHO and members of the Technical Implementation Team, and bi-weekly calls with QualcommWireless Reach.

The RTI Project Manager will hold monthly project update calls with the USAID HealthGov COPand senior leadership to ensure close coordination. The HealthGov COP will in turn keepUSAID informed of project status on a regular basis during project implementation.

Exhibit 19 Proposed project organizational chart.



The Local Project Coordinator will meet bi-weekly with the USAID HealthGov ProvincialCoordinator for Tarlac Province to coordinate project strategy and activities.

The project will form three overlapping groups to ensure that project strategy and activities arecoordinated among project partners, stakeholders, and implementers. These three groups areas follows:

Project Partners Stakeholders Advisory Board Technical Implementation Team

The Project Partners group shall consist of those organizations who have committed funding orin-kind contributions to the project as well as divisions of the DOH responsible for the FHSISand LGUs and MHOs participating in the pilot project. Proposed project partners and their roleshave been described in Section 7. RTI and Qualcomm Wireless Reach will sign a separatememorandum of understanding (MOU) with each partner. Including a project kick-off meeting,the Project Partners will be meet approximately four times at critical points during the project tohelp ensure that the project is on track to achieve the desired results.

The Project Stakeholders Advisory Board shall include the Project Partners as well as keyproject stakeholders that have not committed any funds or in-kind contributions. These mayinclude many of the organizations described in Section 8, as well as organizations not yetidentified. The list of stakeholders and specific stakeholder representatives to be engaged willbe developed with the USAID HealthGov project. Project stakeholder meetings may be heldquarterly. The frequency of project stakeholder meetings will be developed with the USAIDHealthGov project.

The Technical Implementation Team shall consist of members of partner and stakeholderorganizations directly involved in technical implementation issues that include the following:

Developing TSU as a CHITS regional reference site Developing a CHITS software development roadmap prioritizing upgrades and

enhancements Developing and testing software upgrades and enhancements Integrating electronic reporting with the FHSIS Developing and end-user training system and training materials Developing a technical support system for hardware and software

Members of the Technical Implementation Team are likely to include technical representativesof the following organizations:

USAID HealthGov Tarlac PHO CHOs/MHOs TSU



National Telehealth Center, University of thePhilippines

Center for Health Development representativeoffice in Tarlac

Regional Epidemiology Surveillance Unit(RESU), San Fernando City

National Epidemiology Center (NEC) RTI International

The Technical Implementation Team meetings will takeplace monthly using a combination of in-person andremote participation via the Internet.

Exhibit 21 is a Venn diagram depicting the overlapsamong these thee project coordination groups.

13 Monitoring and Evaluation

The RTI project team includes an M&E team with deep experience in designing effective M&Esystems. The RTI project team will develop an M&E plan that focuses on results, developperformance indicators that measure results achievement, include detailed indicator definitions,and specify in detail how data will be collected (Exhibit 24).

Data will be collected for indicator baselines and for quarterly M&E status reports to Qualcomm.The draft M&E plan will be submitted to Qualcomm for review within the first two months of the

Exhibit 20. A Venn diagram depictingoverlaps among the project coordinationgroups.

TechnicalImplementation

Team

StakeholdersAdvisory Board

ProjectPartners

Exhibit 21. Illustrative Results Framework and Indicators

Objective: Apply 3G technology to improve the quality and timeliness of public health care information

Result 1: Improve access to patient records by clinicians

1.A: Number of RHU clinicians who have been trained in the use of the electronic patient records system

1.B: Time spent by RHU clinicians in participating RHUs to complete monthly FHSIS data entry forms Disaggregated by paper forms and electronic patient record system

1.C: Percentage of RHU clinicians who have reported that access to patient records has been improved

Result 2: Automate reporting requirements to improve the quality and completeness of reports

2.A: Number of provincial health office personnel who have been trained to create reports from the electronicpatient records system

2.B: Time spent by provincial health office personnel to enter monthly routine data reports Disaggregated by paper forms and electronic patient record system

2.C: Percentage of participating RHUs that have reported that they were able to submit monthly FHSIS formson time

2.D: The percentage of monthly FSHIS reports submitted by participating RHUs that are missing data



start of the project. It is essential for the RTI team to carry out its initial field work in TarlacProvince during this period to gather the information necessary to develop a feasible andeffective M&E plan. The following proposed Results Framework illustrates project results withassociated performance indicators that are used to measure progress towards achieving projectresults.

In addition to M&E indicators, the RTI project team will propose a set of project milestones.Exhibit 25 is list of illustrative project milestones based on the preliminary project work plan.This list will be revised consistent with revisions to the project work plan.

Exhibit 22. Illustrative project milestones.

Milestone

1 Revised project strategy and work plan submitted to Qualcomm and USAID/HealthGov

2 Sub-grant agreement signed with TSU

3 MOU signed with Smart Communications

4 MOU signed with the National Telehealth Center, University of the Philippines

5 Partners kick-off meeting completed

6 M&E plan finalized

7 M&E baseline data collected

8 Hardware/software platform finalized

9 Local chief executives engaged and informed

10 MOUs signed with pilot LGUs

11 Final draft technical support strategy and plan completed

12 CHO/MHO workshop completed

13 Training modules and documentation completed

14 Clinicians in pilot RHUs trained

15 Computer and communications hardware installed in pilot RHUs

16 Software feature set 1 installed in pilot RHUs

17 Software feature set 2 installed in pilot RHUs

18 Technical support system strategy and manual completed

19 Pilot testing iteration cycle 1 completed

20 Public project launch event completed

21 Pilot testing iteration cycle 2 completed

22 Public event to celebrate completion of pilot testing cycle 2

23 Sustainability and scale-up plan endorsed by project partners

24 Final report submitted to Qualcomm

qualcomm philippines project analysis

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